
Class. 

Book._ 

fopyiightN^, 



CZCEkHIGHT DEPOSm 



DISEASES 

OF 

CHILDREN 

PRESENTED IN TWO HUNDRED CASE HISTORIES OF ACTUAL PATIENTS 

SELECTED TO ILLUSTRATE THE DIAGNOSIS. PROGNOSIS AND 

TREATMENT OF THE DISEASES OF INFANCY AND CHILD- 

HOOD. WITH AN INTRODUCTORY SECTION ON THE 

NORMAL DEVELOPMENT AND PHYSICAL 

EXAMINATION OF INFANTS 

AND CHILDREN 



BY 

JOHN LOVETT MORSE, A.M., M.D. 

Professor of Pediatrics, Harvard Medical School; Visiting Physician at the Children's 

Hospital, and Consulting Physician at the Infants' Hospital and at the 

Floating Hospital, Boston 

THIRD EDITION 



'Wfff 


"^p* 


^^o' 


mmk 



BOSTON 

W. M. LEONARD. PUBLISHER 

1920 






\ 



>° 



COPYEIGHT, I913, 1920, 
BY W. M. LEONARD 



LA576137 



TO 

THOMAS MORGAN ROTCH. M.D., 

THE FATHER OF PEDIATRICS IN NEW ENGLAND. 

THE ORGANIZER OF 

THE DEPARTMENT OF PEDIATRICS 

IN THE 

HARVARD MEDICAL SCHOOL 

AND THE 

FOUNDER OF MODERN SCIENTIFIC INFANT FEEDING. 



AUG ?A ib20 



PREFACE TO THE FIRST EDITION 



The author has found this method of case teaching so useful in 
the instruction not only of undergraduates but also of graduate 
students, who, although older and wiser than in their under- 
graduate days, are still students in the best and widest sense, that 
he felt that there was need for the utiHzation of this method, for 
the presentation of the subject of pediatrics to the practitioner. 

Case teaching, which had been in use for a number of years in 
the Harvard Law School, was introduced into the Harvard Medi- 
cal School in 1900 at the suggestion of Prof. W. B. Cannon, then a 
student in the school. The author believes that this method of 
teaching is far superior to recitations, quizzes, and conferences. 
One of its greatest advantages is that it compels the student to 
think for himself. It is almost as valuable as the cHnical lecture, 
in which the patient is shown, and, except in special instances, is 
more instructive than the didactic lecture. It is surpassed only 
by bedside instruction to small groups of students. 



PREFACE TO THE SECOND EDITION 



The number of case histories has been doubled in this edition in 
order to cover the subject of Pediatrics more fully. An intro- 
ductory section on the Normal Development and Physical Exam- 
ination of Infants and Children has been added, because it was 
beheved that the readers would be able to study and analyze the 
cases better, if they were familiar with the normal development 
and methods of examination. Several reviewers of the first edition 
found fault because the diagnosis was not given at the head of each 
case, not realizing, apparently, that it was omitted in order that 
the reader might study it out for himself. The main object of the 
book is to present a series of problems to be solved by the reader. 
This object would be defeated, if the diagnosis was given in the 
beginning. Several reviewers have complained that there was 

5 



6 PREFACE 

nothing to show whether or not the diagnoses and prognoses were 
correct. It never occurred to the writer that any one would sup- 
pose that they were not. Consequently, nothing was said about 
it. As a matter of fact, the diagnoses are correct in every instance 
in which a positive diagnosis is made. In a few, in which a prob- 
able diagnosis only is made, the children are still ahve. The prog- 
noses are all absolutely correct, except in a few chronic cases in 
which, the children being still ahve, it is impossible to give exact 
data as to the duration of Hfe. The treatment recommended in 
the text was that actually employed. 



PREFACE TO THE THIRD EDITION 



In this edition the book has been thoroughly revised and such 
methods of diagnosis and treatment as have proved themselves 
worthy of adoption in the interim since the last edition suggested 
or advised. On this account the statement made in the second 
edition that "the treatment recommended in the text was that 
actually employed" is now not strictly true. The section on the 
diseases of the gastro-enteric tract has been rewritten and a 
number of new cases substituted for old in the other sections. 
The general plan of the book remains the same. 



TABLE OF CONTENTS 



Pagb 

The Normal Development and Physical Examination of Infants 
AND Children 11-62 

Diseases of the New-born. 

Case I. Prematurity 63 

2. Cystic Hygroma of the Neck 66 

3. Congenital Malformation of the Intestine 68 

4. Congenital Obliteration of the Bile Ducts 70 

5. Encysted Hydrocele of the Cord 72 

6. Cephalhematoma 74 

7. Obstetric Paralysis 76 

8. Hematoma of the Sternocleidomastoid Muscle 79 

9. Congenital Atelectasis 81 

10. Congenital Laryngeal Stridor 84 

11. Congenital Malformation of the Esophagus 86 

12. Physiological Engorgement of the Breasts 89 

13. Icterus Neonatorum 90 

14. Sclerema Neonatorum 92 

15. Granuloma of the Navel 94 

16. Prolapse of Meckel's Diverticulum 96 

17. Hemorrhagic Disease of the New-born 98 

18. Hemorrhagic Disease of the New-bom 102 

19. Septic Infection of the New-bom 105 

20. Omphalitis and Septic Infection of the New-bom 108 

21. Septic Infection of the New-bom no 

22. Erysipelas of the New-born 112 

Diseases of the Gastro-enteric Tract. 

Case 23. Organic Stricture of the Esophagus 118 

24. Spasm of the Pylorus 121 

25. Infantile Pyloric Stenosis 124 

26. Congenital Dilatation of the Colon 127 

27. Intussusception , 130 

28. Intussusception 133 

29. Intussusception 136 

30. Nervous Vomiting 139 

31. Indigestion from Overfeeding — Breast Milk 141 

32. Indigestion from Overfeeding — Artificial Food 144 

33. Indigestion from an Excess of Fat — Breast Milk 146 

34. Indigestion from an Excess of Fat — Acute — Artificial Food . 148 

35. Indigestion from an Excess of Fat — Chronic — Artificial Food 150 

36. Indigestion from an Excess of Fat — Chronic in Child .... 153 

37. Indigestion from an Excess of Sugar — Artificial Food .... 157 

38. Indigestion from an Excess of " Maltose " 159 

39. Indigestion from an Excess of Starch 161 

40. Indigestion from an Excess of Carbohydrates — Chronic in 

Child 163 

41. Indigestion from an Excess of Proteids — Breast Milk .... 166 

42. Indigestion from an Excess of Proteids — Artificial Food . . . 168 

43. Indigestion — Acute — Type undetermined 171 

44. Indigestion with Fermentation 174 

45. Infectious Diarrhea — Dysentery Bacillus 177 

46. Infectious Diarrhea — Gas Bacillus iSo 

47. Cholera Infantum 182 

7 



8 CONTENTS 

Diseases o? the Gastro-enteric Tract (Continued). page 

48 Appendicitis 184 

49. Appendicitis 187 

50. Recurrent Vomiting 190 

51. Constipation 194 

52. Constipation of the Spasmodic Type. Fissure of the Anus . . 197 

53. Incontinence of Feces 200 

54. Pin-worms 202 

55. Roimd Worms 204 

56. Tape Worm 206 

Diseases of Nutrition. 

Case 57. Malnutrition from an Insufficient Supply of Food 215 

58. Malnutrition from an Insufficient Amount of Proteid in the Food 219 

59. Malnutrition from an Insufficient Amount of Breast Milk . . 222 

60. Rickets. Atelectasis of the Lung 225 

61. Rickets and Secondary Anemia 228 

62. Late Rickets 232 

63. Scurvy 236 

64. Scurvy 240 

Specific Infectious Diseases. 

Case 65. Tubercular Peritom'tis 243 

66. Tubercular Peritonitis 247 

67. Tubercular Peritonitis ^ 250 

68. Pulmonary Tuberculosis 253 

69. Pulmonary Tuberculosis 255 

70. Pulmonary Tuberculosis 257 

71. Chronic Diffuse Tuberculosis 259 

72. Tubercular Meningitis 262 

73. Tubercular Meningitis 266 

74. Tubercular Meningitis . 269 

75. Cerebrospinal Meningitis 272 

76. Cerebrospinal Meningitis 275 

77. Typhoid Fever 278 

78. Typhoid Fever 281 

79. Typhoid Fever with Enlargement of the Mesenteric Glands . . 284 

80. Diphtheritic Rhinitis 287 

81. Laryngeal Diphtheria 289 

82. Influenza 292 

85. Malaria 294 

84. Periosteitis. Osteomyehtis 296 

85. Periosteitis and Osteomyehtis 298 

86. Syphilitic Rhinitis 300 

87. Syphilitic Epiphysitis 304 

88. S>T)hiUtic Osteoperiosteitis 307 

89. Clucken-pox 310 

90. Measles 313 

91. German Measles 314 

92. Scarlet Fever 317 

93. Scarlet Fever 320 

94. Mumps 323 

95. Whooping-cough 325 

Diseases of the Nose, Throat, Ears and Larynx. 

Case 96. Adenoids 329 

97. Adenoids 331 

98. Catarrhal Laryngitis S33 

99. Retropharyngeal Abscess , 335 

100. Larjmgismus Stridulus 338 

loi. Otitis Media 341 

102. Otitis Media 344 

103. Otitis Media 346 



CONTENTS -9 

Diseases of the Bronchi, Lungs and Pleuile. Pa«e 

Case 104. Bronchitis 349 

105. Bronchitis 351 

106. Bronchitis 353 

107. Foreign Body in Bronchus 355 

108. Asthma 357 

109. Asthma 360 

no. Bronchopneumonia 363 

111. Bronchopneumonia 366 

112. Pneumonia 369 

113. Pneimionia 372 

114. Pneumonia 376 

115. Serous Pleurisy 379 

116. Purulent Pleurisy 383 

117. Encapsulated Empj^ema 387 

118. Interlobar Empyema 390 

119. Pneumothorax . 394 

120. Sarcoma of the Lung and Liver 396 

Diseases of the Heart and Pericardium. 

Case 121. Congenital Heart Disease 399 

122. Congenital Heart Disease 402 

123. Congenital Heart Disease 404 

124. Functional Heart Disease 407 

125. Acute Endocarditis 410 

126. MaUgnant Endocarditis 413 

127. Chronic Valvular Disease of the Heart 416 

128. Myocarditis 419 

129. Pericarditis with Effusion 422 

130. Pericarditis with Effusion 425 

131. Chronic Adhesive Pericarditis 429 

Diseases of the Liver.' 

Case 132. Fatty Liver 433 

133. Cirrhosis of the Liver 436 

134. Malignant Disease of the Liver 439 

Diseases of the Kidneys and Bladder. 

Case 135. Orthostatic Albuminuria 441 

136. Hematuria 444 

137. Acute Nephritis 446 

138. Pyelitis 452 

139. Pyelitis 455 

140. Sarcoma of the Kidney 457 

141. Chronic Parenchymatous Nephritis 459 

142. Nocturnal Enuresis 462 

Diseases of the Blood. 

Case 143. Secondary Anemia 465 

144. Secondary Anemia 468 

145. Secondary Anemia with Splenic Tumor 471 

146. Pernicious Anemia of the Aplastic Type 475 

147. Lymphatic Leukemia 479 

148. Lymphatic Leukemia 482 

149. Anemia with Splenic Tiunor 484 

150. Pseudoleukemia 488 

151. Banti's Disease 491 

Diseases of the Nervous System. 

Case 152. Habit Spasms 495 

153. Pavor Noctumus 498 

154. Epilepsy 500 



lO CONTENTS 

Diseases of the Nervous System {Continued). Pace 

Case 155. Epilepsy. Chorea 503 

156. Reflex Convulsions 507 

157. Pseudomasturbation 510 

158. Microcephalic Idiocy 513 

159. Amaurotic Idiocy 515 

160. Mongolian Idiocy 518 

161. Chronic Internal Hydrocephalus 521 

162. Chronic Internal Hydrocephalus 524 

163. Chronic Internal Hydrocephalus 527 

164. Tetany 530 

165. Cerebral Hemorrhage 533 

166. Cerebral Paralysis 536 

167. Influenza Meningitis 538 

168. Pneumococcus Meningitis 540 

169. Serous Meningitis 542 

170. Encephalitis 544 

171. Infantile Paralysis 548 

172. Infantile Paralysis 550 

173. Infantile Paralysis 553 

174. Diphtheritic Paralysis 556 

175. Erb's Paralysis 558 

176. Cerebellar Tumor 561 

177. Hysterical Paralysis 564 

178. Sarcoma of the Brain and Skull 566 

179. Amyotonia Congenita 568 

Unclassified Diseases. -^ 

Case 180. Sporadic Cretinism 571 

181. Enlargement of the Thymus 574 

182. Enlargement of the Thymus 578 

183. Status Lymphaticus 581 

184. Cervical Adenitis 585 

185. Bronchial Adenitis 588 

186. Purpura 591 

187. Idiopathic Dropsy 595 

188. Idiopathic Dropsy . 598 

189. Angioneurotic Edema 601 

190. Erythema Multiforme 604 

191. Antitoxin Poisoning • • . 606 

192. Diabetes Mellitus 608 

193. Diabetes Mellitus 611 

194. Diabetes Insipidus 614 

195. Osteogenesis Imperfecta 617 

196. Still's Disease 619 

197. Acute Arthritis of Infants 623 

198. Difficult Dentition 625 

199. Noma 627 

200. Cyst of the Mesentery 629 



SECTION I. 

THE NORMAL DEVELOPMENT AND PHYSICAL 
EXAMINATION OF INFANTS AND CHILDREN, 

A CAREFUL and complete physical examination is of even 
greater value in diagnosis in early life than in adult life, 
because the baby and young child can tell little or nothing 
as to their subjective symptoms. In fact, except in the 
diseases of the gastroenteric tract, the diagnosis must be 
made almost entirely on the findings of the physical exami- 
nation. It is, moreover, easy to misinterpret these findings, 
unless the normal development at different ages is known, 
because what is normal at one age is abnormal at another. 
Unless due attention is paid to these differences, mistakes 
are almost certain to arise. While the methods of exami- 
nation employed are the same at all ages, tne relative value 
of these methods varies with the age of the patient, and 
due allowance must be made for these differences. These 
methods also have to be modified in many ways before they 
are applicable to infants and young children. The attempt 
has been made in the following pages to give the chief 
points in relation to the normal regional anatomy and 
development of children and to describe the proper methods 
of examination. 

Growth in Height and Weight. The rate of growth is very 
rapid in the beginning, especially in the first year. It is still 
rapid, but less so, up to six years. It is then comparatively 
slow until the prepubertal acceleration, which begins in girls 
at about eleven years and in boys at about thirteen years, 
and lasts several years. 

The rate of growth in height and weight are not synchro- 
nous during childhood, but show marked seasonal differences. 
Growth in height is most rapid during the spring and the first 
half of the summer and is often associated with an actual 

Xi 



12 



CASE HISTORIES IN PEDIATRICS. 



loss of weight. It is least rapid during the latter part of the 
summer and autumn. Growth in weight is most rapid 
during the late summer and autumn and least rapid during 
the late spring and early summer. In fact, there is often a 
loss of weight during this period which is equal to, or greater 
than, the gain during the winter and early spring. 

Growth during First Five Years. .The average weight of 
American babies at birth is between seven and seven and 
one-half pounds, the boys averaging a little heavier than the 
girls. The average length of American babies at birth is 
about twenty and one-half inches, the average length of the 
boys being somewhat greater than that of the girls. There 
are numerous statistics as to the rate of growth during the 
first two years, but very few as to that during the next three 
years. The average growth in length during the first year 
is eight inches, and during the second year four inches. In 
general, the birth weight is doubled at five months and nearly 
trebled at a year. The most reliable figures as to the rate of 
growth of American children during the third and fourth 
years are those of Holt (Diseases of Infancy and Child- 
hood, 1 91 6, p. 20) which are based on observations on about 
800 children. They are given in the following table. 

TABLE I. — GROWTH IN HEIGHT AND WEIGHT DURING FIRST 

FOUR YEARS. 



Age. 



Birth . 

1 year. 

2 years 

3 years 

4 years 



[Height. 



Boys. 



Inches. 
20.6 
29.0 
32-5 
35-0 
38.0 



Cm. 
52 
73 
82 
89 
96 



Girls. 



Inches. 
20.5 
28.7 
32-5 
35-0 
38.0 



Cm. 
52.2 
73-2 

82.8 
80.1 

7 



96 



Weight. 



Boys. 



Poimds. 

7-55 
21.00 
27.00 
32.00 
36.00 



Kg. 

3-43 

9-54 

12.27 

14-55 
16.36 



Girls. 



Pounds. 
7.16 
20.50 
26.00 
31.00 
35- 00 



Kg. 
3.26 

931 
II. 81 
14.09 
15-90 



The heights and weights in this table are net; i.e., without shoes or clothes. 



Growth from Five to Fifteen Years. There are several 
large series of observations as to the growth of American 
children after the first five years. Boas (Science, 1895, N. S., 
Vol. I, p. 402) has calculated a table of heights from all the 



NORMAL DEVELOPMENT AND PHYSICAL EXAMINATION. 1 3 

available American material, comprising 45,151 boys and 
43,298 girls, while Burk (American Journal of Psychology, 
1897-8, Vol. 9, pp. 262-3) has calculated one of weights from 
about 68,000 children. Their results are combined in the 
following table. 

TABLE II. — GROWTH IN HEIGHT AND WEIGHT FROM 5 TO 

17 YEARS. 



Age at last birthday. 



5 years 

6 years 

7 years 

8 years 

9 years 

10 years 

11 years 

12 years 

13 years 

14 years 

15 years 

16 years 



Height. 



Boys. 



Inches. Cm. 



41.7 
43-9 
46.0 
48.8 
50.0 
51-9 
53-6 
55-4 
57-5 
60.0 
62.9 
64.9 



105 -9 
III. 5 
116. 8 
123.9 
127.0 
131-8 
136. 1 
140.7 
146.0 
152.4 

159-7 
164.8 



Girls. 



Inches. 



Cm. 
104.9 
no. I 
116. o 



121 
126 

131 

136 

142 

148 

153 

156.4 

157-9 



Weight. 



Boys. 



Pounds. 
41.0 
45-2 
49-5 
54-5 
59-6 
65-4 
70.7 
76.9 
84.8 
95-2 
107.4 
121. o 



Kg. 
18.6 
20.5 
22.5 
24.7 
27.0 

295 
32.1 

34-9 
38. 5 
43-2 
48.8 
55-0 



Girls. 



Pounds , 
39-6 



43 
47 
52 
57 
62 
69 
78 
88 
98 
106 
112 



Kg. 
18.0 
19.7 
21.6 
23.8 
26.0 



28, 
31 
35 
40, 
44. 
48. 
51 



The heights in this table are without shoes. 

The weights are with indoor clothes. These make up for boys approxi- 
mately 8%, and for girls 7%, of the gross weight. 

The term, " age at last birthday," is liable to give a wrong impression, 
because the figures given are really average figures taken from all the children 
from that birthday to the next. A more accurate term is the succeeding 
half-year, i.e., sh years instead of 5 years, the age at the last birthday. 



Relative Growth of Extremities and Trunk. It is well 
known that at birth the legs make up a much smaller pro- 
portion of the total length of the body than they do in the 
adult. There are, however, very few observations as to the 
relation between the length of the legs and that of the body 
at different ages. Grover's (Archives of Pediatrics. 191 5. 
XXXII, 473) figures show that the distance from the lowest 
point of the anterior superior spine of the ilium to the sole 
of the foot is approximately 42.5% of the total length at 
birth, 45-5% at one year, 48% at two years, 53.5% at five 
years, 56% at ten years and 57% at twelve years. His 
figures also^show that the length of the arm, measured from 
high in the axilla to the tip of the middle finger, is approxi- 



14 



CASE HISTORIES IN PEDIATRICS. 



mately 34.5% of the total length at birth, 35% at one year, 
36% at two years, 37.5% at five years, 38.5% at ten years 
and 40% at twelve years. 

Head. The head is relatively large at birth, its circum- 
ference being greater than that of the chest. It increases in 
size very rapidly during the first year. The rate of growth 
then becomes progressively slower and is very slow after five 
years. Excepting in rare instances, such as marked hydro- 
cephalus, the absolute size of the head is of less importance 
in determining whether the head is of normal size or not than 
the relation between that of the head and chest. The chest 
grows faster than the head and surpasses it in size sometime 
during the third year. The following table, copied from Holt 
(Diseases of Infancy and Childhood, 1906, p. 20), shows the 
relations between the head and chest at different ages. 

TABLE III. — CIRCUIVIFERENCE OF HEAD AND CHEST. 



Age. 



Birth 

6 months . 

1 year. . . 

2 years. . 

3 years. . 

4 years . . 

5 years. . 
10 years . . 
15 years. . 



iiead. 



Boys. 



Inches. 



13 


9 


35- 


17 





43- 


18 





45- 


18 


9 


48 


19 


3 


49- 


19 


7 


50 


20 


5 


52. 


21 





53 


2X 


8 


55- 



Cm. 



Girls. 



Inches. 

13-5 
16.6 
17.6 
18.6 
19.0 

195 
20.2 
20.7 
21. 5 



Cm. 

34-5 
42.2 
44.6 
47.2 
48.4 
49-6 

SI. 3 
52.8 
54.8 



Chest. 



Boys. 



Inches. 
134 
16.5 
18.0 
19.0 
20.1 
20.7 
21. 5 

25.8 

300 



Cm. 

34 
42 

45 
48 

51 

52.8 

54-8 

65.6 

76.6 



Girls. 



Inches. 
13.0 
16. 1 
17.4 

18. 5 
19.8 
20.5 
21.0 
24.7 
30.3 



Cm, 
33-2 
41.0 
44-4 
470 

SO. 5 
52.2 

53-5 
63.0 
76.8 



The circumference of the head is the occipi to-frontal. 

The circumference of the chest is at the level of the nipples, midway be- 
tween inspiration and expiration. 



Babies are usually able to hold up the head alone, if the 
back is supported, when they are eight or ten weeks old. 

Shape of Head. Deformities resulting from compression 
during labor are often present at birth, but disappear within 
the first two to four weeks. The head is then rounded and 
symmetrical. Flattening of the back or side of the head 
from constant lying in one position is common and is easily 
overcome by changing the position. Marked asymmetry 
of the head may be present at birth. It usually disappears 



NORMAL DEVELOPMENT AND PHYSICAL EXAMINATION. 1 5 

during the first five or six years. The most common ab- 
normalities in the shape of the head are caused by rickets 
and hydrocephalus. Those due to rickets are the result of 
overgrowth at the centres of ossification in the frontal and 
parietal bones. These overgrowths form prominences on the 
forehead and sides of the head which are often called ^* bosses." 
When they are large and are associated, as they usually are, 
with flattening of the top of the head, the so-called *' square 
head" of rickets results. The hydrocephalic head, on the 
other hand, is rounded and enlarged symmetrically, while 
the whole forehead overhangs. 

Fontanelles. The posterior fontanelle is between one- 
quarter and three-eighths of an inch (i cm.) in diameter at 
birth. This fontanelle closes at six weeks. 

The anterior fontanelle is smaller at birth than a few days 
later, when the head has come into shape. It is then approxi- 
mately one inch (2.5 cm.) in length and seven-eighths of an 
inch (2.2 cm.) in width. It apparently increases somewhat 
in size with the growth of the head during the first six to nine 
months. There is some doubt, however, as to whether there 
really is an absolute increase in size. It then gradually 
diminishes in size and closes at about eighteen months. 
Early closure may be due to a small brain or may be an 
individual peculiarity. Delay in closure is usually due to 
rickets, but may be the result of hydrocephalus or merely 
an individual or family peculiarity. The level of the anterior 
fontanelle is that of the surrounding bones or a little below 
it. Bulging of the fontanelle means an increase in the intra- 
cranial pressure. When chronic this is usually due to chronic 
internal hydrocephalus; when acute, to meningitis. Depres- 
sion of the fontanelle means a decrease in the intracranial 
pressure. This is usually due to a diminution in the amount 
of fluid in the brain as the result of general loss of fluid in 
diarrhea or malnutrition. 

Sutiires. Separation of the cranial bones after birth is 
abnormal, except that the frontal suture may be open in its 
upper part for a few days or weeks. Mobility usually per- 
sists for six months and sometimes for nine months, at which 
time bony union is usually fairly firm. Overlapping of the 



l6 CASE HISTORIES IN PEDIATRICS. 

bones at the sutures is very common in early infancy as the 
result of malnutrition. 

Softening of the bones of the skull, craniotabes, is usually 
due to rickets but sometimes to syphilis. It usually appears 
first along the sutures, about the anterior fontanelle and in 
the occipital bone. The parietal bones are often involved; 
the frontal and temporal, relatively rarely. The best method 
of determining craniotabes is by placing the heels of the 
hands on the forehead and then pressing on the head with 
the tips of the fingers. Imperfect ossification of the bones of 
the skull at birth is a manifestation of delayed or imperfect 
development and is not due to rickets or syphilis. 

Superficial Veins of Scalp. The superficial veins of the 
scalp are usually visible if the hair is not too thick. They are 
always enlarged in chronic internal hydrocephalus and fre- 
quently so in disturbances of nutrition, especially rickets. 
Enlargement of the veins of the scalp without evident cause 
should always suggest the possibility of syphilis. 

Macewen's Symptom, Macewen's symptom is the change 
in the cranial percussion note as the result of certain gross 
changes in the intracranial contents. It is best elicited by 
listening, with the bell of the stethoscope placed on the middle 
of the forehead or over the occipital protuberance, while the 
skull is lightly percussed with the finger tip. The resonance 
is increased and somewhat tympanitic in character when 
there is an accumulation of fluid in the lateral ventricles and 
there is sometimes dullness over a tumor, if it is situated near 
the surface. 

Hair. The first hair is sooner or later replaced by a new 
growth. It sometimes begins to come out in the first few 
weeks and sometimes is retained for several months. The 
new hair may come in quickly or slowly, so that some 
babies always have a considerable amount of hair, while 
others are bald for a long time. Loss of hair on the back of 
the head is sometimes due to rickets but is more often merely 
the result of too soft a pillow, of turning the head from side 
to side in order to see, or of lying too much in one position. 
Coarse hair should always suggest an insufiiciency of the 
thyroid gland. 



NORMAL DEVELOPMENT AND PHYSICAL EXAMINATION. 1 7 

Face. The face is relatively small and the cranium rela- 
tively large at birth, the relation at that time being about 
I to 8, while at five years it is i to 4 and in the adult i to 2. 
If the part of the head below the orbital arches is designated 
as the face and that above them as the cranium, the relation 
of the face to the cranium at birth is approximately i to i, 
and in the adult approximately 2 to i. The shortness of the 
face is due principally to the rudimentary condition of the 
jaws and teeth. The face is relatively much broader in 
relation to its length at birth than in the adult, the relation 
of the breadth to the length at birth being as 10 to 4 and in 
the adult as 9 to 8. 

Nose. The nose is relatively small in infancy and early 
childhood and the bridge rudimentary and relatively wide. 
It is especially wide in cretinism and Mongolian idiocy. A 
depression at the root of the nose in infancy is never due to 
syphilis, but may be in later childhood. 

A nasal discharge is not uncommon in infancy and child- 
hood. This is, in the vast majority of instances, due to a 
simple rhinitis and not to diphtheritic rhinitis or syphilis. A 
thin, irritating discharge, especially if tinged with blood, 
suggests diphtheritic rhinitis, while a muco-purulent or 
purulent discharge, especially if bloody, suggests syphilis. 

Smell. It is probable that the sense of smell is present in 
a rudimentary condition in the newly-born. It develops 
slowly, however, and the ability to detect fine differences in 
odors is not acquired until late in childhood. 

Motion of the alae nasi in respiration points toward some 
disease of the respiratory tract, which is not necessarily 
pneumonia, as is often supposed. It is often present in 
infancy, however, when there is no trouble in the respiratory 
tract and is, therefore, of relatively little importance. 

Lips. Fissures and rhagades are usually manifestations 
of syphilis, but may be due to malnutrition and infection 
from any cause. 

Mouth. The examination of the mouth and throat is best 
left until the last, because infants and young children are 
often much disturbed by it. If it is done first they are very 
likely to become frightened and resist further examination. 



1 8 CASE HISTORIES IN PEDIATRICS. 

The mouth is normally kept closed. An open mouth is 
usually due to obstruction in the nose or nasopharynx. The 
most common cause of this obstruction is adenoids. It must 
be remembered, however, that babies and young children are 
very likely to open their mouths, if they are interested. 
Idiots are also very likely to keep their mouths open. 

A rounded swelling is often visible on each side of the mouth 
between the jaws during infancy. These swellings are the 
so-called ''sucking pads," which are collections of fat, enclosed 
in a capsule, lying outside the buccinator muscles. They 
become much smaller after infancy, but are often visible 
throughout childhood. 

The roof of the mouth is, as a rule, flatter in infancy than 
in childhood, the arching becoming more marked as the 
alveolar ridges develop. The normal variations in the arch 
of the hard palate are, however, very great. An excessive 
degree of arching is in most instances the result of inter- 
ference with the nasal respiration, this interference usually 
being due to adenoids. It is sometimes, however, a stigma 
of degeneration. The soft palate is more horizontal in in- 
fancy than later, while the uvula is very small. 

One or more small white or yellowish-white nodules are 
often visible in the median line of the hard palate at or near 
its junction with the soft palate during the early weeks or 
months of life. These are accumulations of epithelial cells 
and are known as Epstein's Pearls. A small protuberance 
is often visible on each side of the soft palate. These are 
the tips of the hamular processes of the sphenoid bone. The 
mucous membrane over these processes is very thin, and, as 
the result of mechanical injury, erosions and ulcerations often 
occur in these areas. These lesions constitute the condition 
known as Bednar's Aphtha, and are not manifestations of 
syphilis or tuberculosis, as is often supposed. Similar lesions 
also frequently occur over and about Epstein's pearls. 

The mouth is relatively dry during early infancy, because 
but little Saliva is secreted during the first three or four 
months. The secretion then increases rapidly in amount. 
A considerable proportion runs out of the mouth at first, 
however, because the baby does not know enough to swallow 



NORMAL DEVELOPMENT AND PHYSICAL EXAMINATION. I9 

it. When he learns how, drooling ceases. There is no 
etiological connection between drooling and dentition. They 
merely appear coincidently. 

Koplik's spots J which are pathognomonic of measles, are 
situated on the buccal mucous membrane. They are rose- 
red spots, the size of the head of a pin, or somewhat larger, 
with a pearly white spot, the size of the point or shaft of a 
pin, in the centre. 

Tongue. The tongue is lightly coated, especially pos- 
teriorly, during the early months. This coating is due to the 
fact that, owing to the deficiency of the salivary secretion, 
the desquamating epithelium is not washed away as it is later. 

Enlargement of the tongue in infancy may be a congenital 
malformation, but is more often a manifestation of cretinism. 
The tongue is also enlarged in Mongolian idiocy in childhood, 
but not in infancy. 

Ulceration of the under surface of the tongue at or near the 
frenum is not very uncommon as the result of the irritation 
of the lower incisor teeth or infection (Riga*s or F6de's 
Disease). It does not necessarily indicate whooping-cough 
as is sometimes taught. 

Taste. The sense of taste is well developed at birth. 

Teeth. Infants are sometimes born with teeth. The first 
tooth usually appears at six or seven months. The teeth 
usually erupt in groups with considerable regularity. There 
are so many normal variations, however, that it is difficult 
to lay down any hard and fast rules. In a general way the 
first, or temporary teeth, erupt as follows: 

2 middle lower incisors, 6-8 mos. 

4 upper incisors, 8-10 mos. 

2 lateral lower incisors, 

4 anterior molars, 

4 canines, 18-20 mos. 

4 posterior molars, 24-30 mos. 

20 

Delay or irregularity in cutting the teeth may be due to 
rickets or may be merely an individual or inherited peculiarity. 



12-15 n^os. 



20 CASE HISTORIES IN PEDIATRICS. 

It IS not Wise to attribute delay in dentition to rickets, unless 
there are other signs of the disease present. Disturbances 
of nutrition, other than rickets, seldom delay dentition. 
They often result, however, in an imperfect development of 
the enamel and a tendency to early decay. Syphilis never 
produces any characteristic changes in the first teeth, its 
action being the same as that of other disturbances of nutri- 
tion. The first of the second, or permanent, teeth are the 
so-called "six-year old" molars, which appear at this time 
behind the posterior molars of the first dentition. The 
permanent teeth then begin to replace the temporary teeth, 
the bicuspids taking the place of the temporary molars, after 
which the permanent molars erupt posteriorly. The per- 
manent teeth erupt in a general way as follows, the lower 
teeth usually preceding the upper: 

4 first molars, 6 years 

4 middle incisors, 7 years 

4 lateral incisors, 8 years 

4 first bicuspids, 9 years 

4 second bicuspids, lo years 

4 canines, 12-13 years 

4 second molars, I2-I5vyears 

4 third molars, 17-25 years 

32 

The permanent teeth often show, in the same way as the 
temporary, an imperfect development of the enamel and a 
tendency to early decay, if the nutrition has been disturbed 
during early childhood. They also show the typical lesions 
of syphilis, the so-called ''Hutchinson teeth." 

Projection of the upper teeth, like crowding together of 
the upper teeth, is usually the result of imperfect nasal 
breathing, ordinarily due to adenoids, and not of thumb- 
sucking as was formerly supposed. 

Throat. It is impossible to obtain a satisfactory view of 
the throat unless the child is held properly. It must, in the 
first place, be held so that the light shines into its throat, 
that is, facing a window or a light. It should be held in the 




Method of holding infant for examination of the throat. 




Method of holding child for examination of the throat. 



NOR^IAL DEVELOPMENT AND PHYSICAL EXAMINATION. 21 

upright position; otherwise it is impossible to properly 
extend the head. The person that holds the child should 
look after the body and extremities. The examiner then 
holds the head with his left hand and takes the spoon or 
depressor in his right. If the examiner wishes to use both 
hands, as in taking a culture, the head also can be held by 
the person holding the child, or, if it is too strong to be held 
in this way, by a third person. 

If the child refuses to open its mouth it can usually be made 
to do so by working the spoon or depressor in gradually from 
the side, by pushing it in when it cries, or by pinching the 
nose. 

The throat cannot be properly examined unless the child 
is made to gag. This can be done by placing the spoon or 
depressor on the back of the tongue and pressing downward 
and forward. It is useless to press on the front or middle of 
the tongue. This merely pushes the back of the tongue 
upward and obscures the view of the throat. 

Inspection of the throat is not sufficient, if there are any 
symptoms of obstruction to either respiration or deglutition. 
In such instances a digital examination of the throat should 
always be made, as it is perfectly possible to miss a retro- 
pharyngeal abscess if reliance is placed on inspection alone. 
A gag should never be used when the presence of a retro- 
pharyngeal abscess is suspected, because sudden death 
sometimes results if the jaws are widely separated in this 
condition. 

The tonsils are relatively larger throughout childhood than 
in adult life and normally increase in size at the time of the 
eruption of the molars. 

The epiglottis is visible in infancy and early childhood 
when the tongue is depressed and the patient made to 

Esophagus. The distance from the gums to the cardia 
in the new-born is seventeen cm. (6f inches) ; from the 
incisor teeth to the cardia at three years, twenty-three to 
twenty-four cm. (9-9! inches); and at six years, twenty- 
seven cm. (lof inches). After swallowing a gurgling sound 
is normally heard at the left of the spinous processes as far 



22 CASE HISTORIES IN PEDIATRICS. 

down as the eighth dorsal spine. In childhood the squirt- 
ing sound of liquids passing through the cardia into the 
stomach is heard in the epigastrium about five seconds after 
swallowing. 

Nasopharynx. The nasopharynx is very low at birth, but 
relatively long from before backward. It increases rapidly 
in height during the first six months, but very slowly during 
the rest of infancy. It changes gradually toward the adult 
type, but is relatively low during the whole of childhood. 
Adenoid tissue is present in the nasopharynx at birth and 
may even then be sufficient to cause obstruction. 

It is impossible to examine the nasopharynx with the mirror 
until the child is old enough to assist. This is usually not 
before it is eight years old. Prior to this time the examina- 
tion must be made with the finger. This is somewhat 
difficult in infancy because of the small size of the parts, but 
can almost always be done if the examining finger is not too 
large. Care must be taken not to use force and thus tear 
the soft palate. The best way to examine is to stand behind 
the patient, holding the mouth open with the left forefinger 
or a gag, according to the age of the child, and introducing 
the right forefinger into the mouth. When held in this 
position the child is unable to get away. 

The maxillary antrum is present at birth and the ethmoidal 
cells develop at about three years. The frontal sinuses are 
not developed until seven years. 

Ear. No physical examination is complete in infancy and 
early childhood, unless some satisfactory explanation of the 
symptoms has been found elsewhere, without an examination 
of the middle ear. Disease of the middle ear cannot be ruled 
out, as is so often done, because there is no discharge. The 
absence of pain, of putting the hand to the ear and of tender- 
ness over the mastoid, do not at this age by any means 
exclude the presence of disease of the middle ear. In fact, 
these symptoms are more often absent than present. The 
ear must be examined with the speculum. In this way only 
can the condition of the middle ear be determined. A smaller 
speculum than comes with most sets is needed to examine a 
young infant's ears. 




Method of examination for Adenoids. 




Showing mouth-breathing and funnel chest as a result of Adenoids. 



NORMAL DEVELOPMENT AND PHYSICAL EXAMINATION. 23 

In infancy the external auditory canal runs downward 
and inward. The ear must, therefore, be pulled downward 
and a little forward to straighten the canal instead of upward 
and backward, as in older children and adults. It must also 
be remembered that the drum is more horizontal at this age 
than later. 

Hearing. Infants hear little or nothing during the first 
few days of life, probably because of the swelling of the 
mucous membrane of the tympanum and the absence of air 
in the middle ear. The hearing rapidly improves, however, 
and in a short time becomes very acute. 

The mastoid antrum is present at birth, but the mastoid 
cells are usually not developed. They are, however, fairly 
well developed at three years. 

Eyes. The eye is anatomically developed at birth. 
Vision is, however, probably very feeble. A strong light 
evidently causes discomfort during the first few weeks. The 
baby does not usually fix its eyes until it is at least six 
weeks old and coordination is not well developed until three 
months or later, at which time it seems to recognize objects. 
It is, therefore, of little use to attempt to test the accommoda- 
tion in young infants. The pupils react to light almost 
immediately after birth, and this test can, therefore, be used 
at once. It is best performed by bringing a light from above 
the head downward in front of the eyes. 

The function of the lachrymal glands is not developed at 
birth. Tears are shed, as a rule, at about three months. 

Neck. The neck is relatively short during Infancy, because 
of the large size of the head and its tendency to fall forward, 
the high position of the sternum and the large amount of 
fat tissue. The neck Is also short and thick in cretinism. 

Spine. The spine is largely cartilaginous at birth, ossifi- 
cation not being complete until the thirtieth year. It is, 
therefore, extremely flexible during infancy and early child- 
hood. The infant is usually not able to sit up alone until he 
is about eight months old. The lumbar curve is less marked 
in the infant when sitting than in the child and adult. When 
infants are forced to sit up before they are able, or when 
infants and young children are feeble from any cause, they 



24 CASE HISTORIES IN PEDIATRICS. 

usually sit with a marked general kyphosis, most marked in 
the lower dorsal region, the so-called "curve of weakness." 
This disappears when they lie down. It is important not to 
mistake this condition for the kyphosis due to disease of the 
spine, which is localized and does not disappear on lying 
down. 

It is very difficult to count the spinous processes in the 
infant and young child, though it is easy to do so in older 
children. The first dorsal spine, not the seventh cervical, is 
usually the most prominent in infancy. Failure to appreci- 
ate this fact is likely to lead to error. The spine of the fourth 
lumbar vertebra is at the level of the highest point of the 
crest of the ilium at all ages. This fact is of importance in 
relation to the operation of lumbar puncture. In this con- 
nection it is important to remember that at birth the spinal 
cord extends to the third, and after one year to the second, 
lumbar vertebra. 

Spina bifida with meningocele is obvious; it is easy, how- 
ever, to overlook spina bifida occulta. Pigmentation of the 
skin or an unusual growth of hair is very common over the 
site of this malformation and should suggest its presence. 

Chest. The relative sizes of the chest and head at dif- 
ferent ages have already been discussed and are given in 
Table III. 

The shape of the chest in infancy and early childhood is 
materially different from that in older childhood and adult 
life, the chest being rounder and shorter. The relation of 
the antero-posterior diameter to the lateral diameter of the 
interior of the thorax at birth is as two to three, while in the 
adult it is as one to two and one-half or one to three. The 
ribs bend much less backward than in the adult and are more 
nearly horizontal. The top of the sternum is higher and the 
lower angle of the ribs more obtuse. The change from the 
infantile to the adult type of thorax is nearly complete, 
however, at five years. 

The sternum is narrow and almost entirely cartilaginous at 
birth, while the front of the chest is almost entirely made up 
of the costal cartilages, the ribs themselves being relatively 
much shorter than in later life. The chest is, therefore, more 



^^H '< ^ I ^« ^ 


■ 


^^. "^ •, .Sri 

U^:^^^. ^ ... J; 


1 

1 



Position of Rosary. 




Extreme deformity of the chest in Rickets. 



NOR^IAL DEVELOPMENT AND PHYSICAL EXAMINATION. 25 

compressible and elastic in infancy and early childhood than 
later. Deformities of the chest, such as bulging of the 
precordia over an enlarged heart, are, for the same reason, 
more easily produced. When the intrathoracic pressure is 
increased, as in pleural effusion, the whole chest wall yields 
for the same reason before the intercostal spaces bulge. 

Engorgement of the breasts with the secretion of a fluid 
resembling colostrum in appearance is not uncommon in the 
newly-born of both sexes. It usually appears from the third 
to the fifth day and persists for several weeks. It is a phy- 
siological, not a pathological, condition. The secretion is 
true milk and contains between 2.5% and 3% of fat, about 
2.5% of sugar and from 2.5% to 3.5% of proteids. 

Deformities of the chest are not at all uncommon in infancy 
and early childhood and at this age are in the vast majority 
of cases due to rickets. In later childhood they are most 
often due to tubercular disease of the spine, disease of the 
pleura or weakness of the muscles. 

The most common abnormality in the chest caused by 
rickets is the ''Rosary." This is caused by an overgrowth 
of tissue at the junction of the ribs with their cartilages, which 
results in the formation of a series of prominences resembling 
beads. These, on account of the relative shortness of the 
ribs at this age, are situated farther out from the median line 
than is usually supposed. The line of junction of the ribs 
and their cartilages is always palpable in thin babies and it 
is sometimes difficult to distinguish this normal condition 
from a beginning rosary. It is a safe rule not to call anything 
a rosary unless a prominence can be felt at the sides of the 
junction of the ribs and cartilages as well as on the anterior 
surface. The beading usually appears first on the lower 
ribs. 

The deformities of the chest in rickets are due primarily 
to the softening of the bones in this disease, which renders 
them unable to resist the pressure of the atmosphere and the 
pull of the muscles. Interference with free respiration, as by 
adenoids, increases the degree of the deformities. The most 
common deformity is a flattening of the sides of the chest. 
When this is localized and rather sharply defined, it is known 



26 CASE HISTORIES IN PEDIATRICS. 

as "Harrison's groove." The flattening of the sides of the 
chest is usually accompanied by a flaring of the lower ribs, 
presumably due to the resistance of the large liver and the 
distention of the abdomen, so common in this disease. The 
flattening of the sides of the chest results in an increase in the 
antero-posterior diameter with a consequent prominence of 
the sternum. This, when marked, is known as ''pigeon 
breast" or ''chicken breast." A depression of the sternum 
resulting in the so-called "funnel chest" sometimes develops 
in rickets, but is more often a congenital anomaly. 

Diaphragm. The central point of the diaphragm is 
probably somewhat higher in relation to the spine in infancy 
than in later childhood. The evidence on this point is, 
however, not very conclusive. The diaphragm reaches the 
adult position at five or six years, or a little later. 

Position in Examination of the Chest. The best position for 
the examination of the front of the chest of an infant or small 
child is lying on its back. It is less likely to be frightened 
when lying on someone's lap than on a bed or table. An 
older child can be examined equally well when sitting up. 
The best position for the examination of the back of the chest 
of an infant or small child is in the nurse's arms with its arms 
around her neck. In this position there is no interference 
with respiration and the air can enter both sides alike, while 
the baby feels at home and is less likely to be frightened. 

If the baby is too sick to be taken up it may be turned on 
its face. This is less satisfactory, however, because the 
weight of the body on the soft front of the chest interferes 
with full respiration. The back should never be examined 
when the baby is lying on its side, because the weight of the 
body on the elastic chest wall interferes materially with the 
entrance of air into the lower side and therefore diminishes 
the respiratory sound on this side, which may lead to errone- 
ous conclusions. It is unwise to examine an older child 
when lying on its side, but the chances of error are less than 
in infancy. Older children are best examined when sitting 
up or lying on their faces. 

It is usually wiser to examine the back of the chest of 
infants and small children before the front as, in this way they 




Method of holding baby for examination of back of chest. 




Pigeon Breast. 




Retraction of the chest at the insertion of the diaphragm. 



NOR^IAL DEVELOPMENT AxND PHYSICAL EXAMINATION. 27 

are less likely to be frightened. It is also wiser to auscult 
before percussing, partly because ausculation is less likely 
to frighten the babies than is percussion and partly because 
at this age the results obtained by auscultation, are, as a rule, 
more reliable than those obtained by percussion. 

Stethoscope. The stethoscope is, on account of the small 
size of the parts, far preferable to the naked ear in the exami- 
nation of infants and young children. It is very important, 
moreover, to use a stethoscope with a small bell; one with 
a diameter of three-quarters of an inch (2 cm.) is amply large 
enough. It is impossible to get a larger bell down on the 
chest of a thin baby, and a large bell transmits the sounds 
from too large an area and makes it impossible to locate their 
source accurately. The bell of the phonendoscope will, for 
example, cover nearly the whole of an infant's heart. 

Heart. The volume and weight of the heart relatively to 
the body weight are greatest in the new-born, sink rapidly in 
the first and second years, increase again for a time, are 
smallest in the years before puberty and increase rapidly 
during puberty, reaching the adult relation. 

The cardiac physical signs vary materially at different 
periods of infancy and childhood, because of the varying 
rapidity of the growth of the heart, thorax and other organs. 
In infancy, the comparatively large heart is placed more 
horizontally in the narrow thorax and is covered to a less 
extent by the lungs than it is later, giving, therefore, a set 
of physical signs materially different from those found in 
later childhood and adult life. The physical signs gradually 
approach the adult type with the development of the organ- 
ism. The infantile form of thorax is replaced by the adult 
type between four and five years, while the diaphragm 
reaches the adult position at five or six years, or a little later. 
The lungs are not fully expanded forward until six years or 
later. The thymus modifies the signs in infancy and possibly 
for two or three years longer. 

Cardiac Impulse. The cardiac impulse is rarely visible 
and frequently not palpable in early infancy. Later it is 
more distinct than in adults. Owing to the anatomical 
conditions already mentioned, it is at first higher up and 



28 CASE HISTORIES IN PEDIATRICS. 

farther out than in later life. In infancy it is in the fourth 
space about one cm. (| inch) outside the nipple line and from 
five cm. (2 inches) to six cm. (2f inches) from the median line. 
As the result of the anatomical changes due to growth, it 
gradually moves downward and then inward, being in the 
fifth space in the nipple line at seven years, and always inside 
the nipple line by the thirteenth year. 

Cardiac Area. The area of the relative cardiac dullness, 
because of the anatomical peculiarities already mentioned, 
is relatively larger than in adult life, and relatively larger in 
infancy and at puberty than at other periods of childhood. 
The area of absolute dullness — that part of the heart 
uncovered by lung — is relatively larger than in adults until 
the lungs are fully expanded at six years. On account of the 
small size of the parts it is impossible to determine accurately 
the area of absolute dullness in infancy. The usual mistake 
is in making the area too large. The right border is at the 
left sternal border throughout the whole of childhood. 
Fortunately the knowledge of this area is of relatively little 
importance. It is comparatively easy, however, to deter- 
mine the area of relative dullness, which is the important one. 
In the first two years the dullness of the thymus may interfere 
with the determination of the upper border of the heart, but 
it can usually be made out by the aid of strong percussion. 

In infancy, the upper border of relative dullness is at the 
lower border of the second costal cartilage or in the second 
space. The left border is one cm. (f inch) outside the nipple 
line, or from five cm. (2 inches) to six cm. (2f inches) to the 
left of the median line, the right border at, or just inside, the 
right parasternal line, or two cm. (| inch) to the right of 
the median line. 

At six years, the upper border of relative dullness is at 
the upper border of the third rib, the left border just outside 
the left nipple line, or seven cm. (2f inches) to the left of the 
median line, the right border two and one-half cm. (i inch) 
to the right of the median line. 

At twelve years, the upper border of the relative dullness 
is at the third rib, the left border one cm. (f inch) inside 
the left nipple line, or eight cm. (3I inches) to the left of the 




Area of cardiac dullness in infancy. 




Area of cardiac dullness at six years. Area of cardiac dullness at twelve years. 



NORMAL DEVELOPMENT AND PHYSICAL EXAMINATION. 29 

median line, the right border three cm. (i| inches) to the 
right of the median line. 

Heart Sotmds. In early infancy the first sound lacks the 
booming quality heard later and is much more like the second 
sound, so that the sounds often resemble the *'tic-tac" heart 
of the foetus. The first sound acquires the normal booming 
character during the second year. The first sound at the 
apex is relatively much louder in comparison with the first 
sound at the base in infancy and early childhood than in 
later life. The second pulmonic sound is louder than the 
second aortic throughout the whole of childhood. For this 
reason great care must be exercised in diagnosing an accentua- 
tion of the second pulmonic sound. Reduplication of the 
second sound is not uncommon under normal conditions. 
When this occurs alone, it is, therefore, not necessarily 
pathological. 

Pulse Rate. The rate of the pulse is very irregular in 
infancy, even under normal conditions. It varies markedly 
as the result of exertion, excitement or any slight disturbance. 
The rhythm is very easily disturbed. The pulse also becomes 
irregular from very slight causes in early childhood. Irregu- 
larity of the pulse is, therefore, of comparatively little sig- 
nificance in infancy and early childhood. It is impossible, 
for these reasons, to give more than approximate figures as 
to the pulse rate at these ages. 

Early weeks, 120-140 

First year, II o-i 20 

Second year, loo-iio 

Two to five years, 90-100 

Five to ten years, 80- 90 

The pulse rate increases very markedly from slight causes 
in infancy and early childhood, and a very high rate may be 
quickly reached. Increased frequency of the pulse is, there- 
fore, of less significance at this age than later. 

Blood Pressure. The blood pressure in childhood varies 
with age, but not with sex. The general condition makes a 
great difference in infancy, the pressure being much lower in 
feeble or premature infants. It is lower when the baby is 



30 



CASE HISTORIES IN PEDIATRICS. 



asleep than when it is awake, when it is quiet than when it 
is moving or crying, and before than after feeding. 

BLOOD PRESSURE. 
Age in Years 



Systolic Pressure . 
Diastolic Pressure 
Pulse Pressure .... 



Under 2 


3 


4 


5 


6 


90 
66 
25 


91.8 
65.6 
26.2 


91.6 
64.9 
26.7 


913 
64.4 
26.9 


92.6 
67.3 
25-3 



94.0 

66.3 

26.9 



8 


9 


10 


II 


12 


13 


14 


15 


93-6 
64.7 
28.9 


94-3 
71.0 

23-3 


99.2 
67.1 
32.1 


97.1 
65.5 
31-5 


102.3 
65.2 
37.1 


103.6 
70-5 
33-1 


106. 1 
67.4 
38.7 


105.6 
67.5 
38.1 



Under 2 years — Morse & Wyman. Amer. Jour. Dis. of Child. 1914. VIII, 270. 
Over 2 years — Judson & Nicholson. Amer. Jour. Dis. of Child. 1914. VIII, 257. 

Venous hums are even more common in infancy and early 
childhood than later. A systolic murmur is often heard at 
the pulmonic area, and is functional in origin. Functional 
systolic murmurs are often heard also in the great vessels 
of the neck. A systolic murmur, increased on extension of 
the head, is often heard under the manubrium in infancy. 
In fact, it can be elicited in almost every infant by the 
hyperextension of the head. This murmur is probably due 
to the pressure of the thymus on the vessels. It is not 
pathological. 

Lungs. Percussion. Percussion of the lungs gives, in 
infancy and early childhood, less reliable information than 
auscultation. They have the same relative value in later 
childhood as in adult life. Finger percussion should always 
be employed. It is necessary to percuss lightly, because of 
the small size of the parts. Strong percussion is likely to set 
more than one organ in vibration and thus produce mixed 
sounds, which lead to confusion. It is very difficult to make 
out the lung borders accurately in infancy because the plex- 
imeter finger often covers a rib and a space, or even two ribs 
and a space, while the tip of a large finger is almost as large 
as the superficial cardiac area. It must be remembered that, 
owing to the compressibility of the chest, the resonance is 
impaired on the under side, if an infant is laid on its 
side. 

Resonance. The lower border of the lungs in infancy is, 
owing to the somewhat higher position of the diaphragm, 




Position of lobes of lungs in front. 




Position of lobes of lungs behind. 



NOILMAL DEVELOPMENT AND PHYSICAL EXAMINATION. 3 1 

about one rib higher than in later life. The lower border 
of the lung resonance is, therefore, at the fifth rib in the right 
mammillary line, the seventh rib in the midaxillary line and 
the tenth rib in the scapular line. The lower border in the 
left midaxillary and scapular lines is about one space lower 
than on the right. There is no pulmonary resonance under 
the sternum during infancy, because the anterior borders of 
the lungs do not extend under the sternum at this age. The 
lung does not extend as far over the heart at this time as later, 
but the parts are so small that percussion of the lung-heart 
border is practically impossible. The adult relations are 
attained at about six years. 

The relation of the lobes to the chest wall is essentially the 
same in infancy and childhood as in adult life. The line 
between the upper and lower lobes starts in the median line 
of the back at the level of the spines of the scapulae, runs 
through the fourth rib in the midaxillary line and reaches the 
border of the lung at the sixth rib in the mammillary line on 
the left and the parasternal line on the right. The line 
between the upper and middle lobes on the right side diverges 
from the line between the upper and lower lobes at the outer 
border of the scapula, runs through the third rib in the mid- 
axillary line and reaches the border of the lung in front at 
the fourth costal cartilage. 

The percussion note is normally more resonant during 
infancy and childhood than in later life. Under normal 
conditions there is always a tympanitic element added at the 
left base, because of the proximity of the stomach. When 
the abdomen is distended with gas this tympanitic element 
is greatly exaggerated on the left side and may be present on 
the right side also. 

Percussion of the apices in Infancy and early childhood 
is impossible because of the small size of the parts. The 
percussion note is not higher pitched at the upper part of the 
right lung, as it is in adults. On the contrary, there is an 
area of impaired resonance under the inner third of the left 
clavicle up to nine or ten years, although it is difficult to 
elicit it in infancy. This area of dullness is due to the pres- 
ence of the great vessels and the esophagus on this side, and 



32 CASE HISTORIES IN PEDIATRICS. 

the fact that the left lung does not extend as far forward as 
the right. 

Grocco's sign is found in infancy and childhood under the 
same conditions as in adult life and is of the same significance. 

A very important point in the examination of the chest in 
infancy is the Sense of Resistance, meaning by this term 
the resistance felt when tapping the chest with the ends of 
the fingers, not that felt on ordinary percussion. Much can 
be told as to the conditions within the chest in this way at 
this age, because of the thinness of the chest walls. This 
method of examination is of especial importance in the 
diagnosis between pleural effusions and consolidation of the 
lung, because the sense of resistance is much greater over an 
effusion than it ever is over a solid lung. 

Respiration. The respiratory rhythm is often very irregu- 
lar under normal conditions during the first two years. It 
is not uncommon for infants to hold their breath for a long 
time during auscultation. This is always strong evidence 
that there is no serious disease of the respiratory system. 

The respiration is predominantly diaphragmatic in type 
during the first years, the thoracic element not being markedly 
developed until the seventh year. The variation in the type 
of respiration according to sex does not manifest itself until 
the tenth year. An inspiratory recession of the epigastrium 
is physiological in the early months of life. It is very difficult 
to give figures as to the rate of respiration at different ages, 
because it varies so much in different individuals and accord- 
ing to whether the child is asleep or awake, quiet or active. 
The following figures are approximately correct when the 
children are quiet. 

At birth, 40-45 per minute 

During the first two years, 25 per minute 

At six years, 20 per minute 

At ten years, 18 per minute 

The respiratory sound is normally higher pitched up to 
late childhood than in adult life; that is, it is slightly changed 
from the vesicular toward the bronchial. This modification 
of the respiration is usually spoken of as puerile. It is 



NORMAL DEVELOPMENT AND PHYSICAL EXAMINATION. 33 

often mistaken for bronchial respiration, especially when the 
respiratory sound is diminished on one side, the mistake 
being due to the fact that proper attention is not paid to the 
difference between the quantity and quality of the respiratory 
sound. It will not be mistaken for bronchial respiration if 
it is remembered that when the character of the sound is the 
same on both sides, back and front, it cannot be bronchial. 
If there is any doubt as to whether respiration is puerile or 
bronchial, it can always be settled by comparing it with the 
respiratory sound heard over the trachea or at the root of 
the lungs, which is, of course, always bronchial. 

Bronchial respiration is heard normally over a wider area at 
the root of the lungs in the back in infancy and early child- 
hood than in late childhood and adult - life. It is almost 
always heard in the interscapular space and may extend a 
little beyond the inner borders of the scapulae. It is important 
to remember that bronchial differs from vesicular respiration 
in two particulars : the character of the sound and the greater 
length of the expiration. In infancy, owing to the normal 
variability in the relative length of inspiration and expiration, 
the character of the sound is of more importance than the 
relation between inspiration and expiration. The character 
of the respiratory sound is the same at both apices in infancy 
and early life, and the expiration is not prolonged at the right 
apex. 

An area of dullness and bronchial respiration is often found 
in the left back between the scapula and the median line at 
about the level of the angle of the scapula when there is an 
effusion into the pericardium or when the heart is much 
enlarged. This area is due to the compression of the lung. 

The respiratory sound is often so feeble in infancy, espe- 
cially if there is disease of the lungs, that it is impossible to 
determine its character. In such instances the baby must 
be made to cry and thus to take a long breath. In this way, 
and in this way only, can a satisfactory examination be made. 
It is important to remember also that the respiratory sound 
is diminished on the lower side if the baby lies on its side. 
Failure to appreciate this fact often leads to a mistaken 
diagnosis of pneumonia on the upper side, the normal puerile 



34 CASE HISTORIES IN PEDIATRICS. 

respiration being mistaken for bronchial because of the 
greater intensity of the sound on the upper side. 

Pneumonia. Certain points as to the respiratory sound 
in pneumonia in early life are worthy of mention. A diminu- 
tion in the respiratory sound, without change in its character, 
is often the earliest sign- It is the character, not the inten- 
sity, of the respiratory sound which is of importance in 
distinguishing between bronchial and vesicular respiration. 
Satisfactory conclusions cannot be drawn unless the baby is 
made to breathe deeply. Bronchial respiration is often heard 
first high up in the axilla. The examination is not complete 
unless the axillae are examined. Loud bronchial respiration 
does not prove the presence of pneumonia and rule out a 
pleural effusion, because loud bronchial respiration is often 
heard when there is an effusion. Conversely, diminution 
in the respiratory sound, even when bronchial, does not 
exclude pneumonia, because the respiration is often dimin- 
ished on the affected side in this disease. 

Voice Sounds. What has been said regarding the char- 
acter and intensity of the respiration applies equally well to 
the voice sounds. Reliance has to be placed, of course, in 
infancy, on the cry, not on the spoken voice. A change in 
the character of the voice sounds is often noticeable before 
there is any change in the respiratory sound, when there is 
beginning solidification of the lungs. 

Tactile Fremitus. The fremitus, like the voice sounds, has 
to be determined in infancy from the cry rather than from 
the spoken voice. It is comparatively hard to distinguish 
any but marked variations in the fremitus at this age, and, 
owing to the elasticity of the chest wall, the fremitus is often 
transmitted unimpaired, even when there is a large collection 
of fluid in the chest. It is, therefore, of relatively little 
importance in infancy. 

Rales. The character, varieties and significance of rales 
are the same in early infancy as in adult life. They often 
sound louder at this age, however, because of the thinness of 
the chest walls, and, for the same reason, are more often 
palpable. Rales made in the nose or nasopharynx are often 
transmitted to the chest in infancy and are often mistaken 



NORMAL DEVELOPMENT AND PHYSICAL EXAMINATION. 35 

for bronchial riles. They can, however, be easily distin- 
guished. Bronchial rales are not audible over the cheeks 
and trachea and are never exactly the same on both sides 
and on the front and back. Riles made in the nose and 
nasopharynx are usually audible over the cheeks, always 
audible over the trachea, and sound exactly the same over 
the trachea and over both lungs, both back and front. 

Pleural Friction Sounds. These sounds are, for some 
unknown reason, almost never heard in infancy, although 
inflammation of the pleura is common enough at this age. 
They are heard in childhood as frequently, and under the 
same conditions, as in adult life. 

Thjrmus. The thymus may normally extend a little above 
the sternum. Practically, it is not palpable under normal 
conditions. If it is palpable, it is almost certainly enlarged. 
It is claimed that by light percussion the thymus gives in 
infancy the area of dullness shown in the accompanying 
diagram. 




Dullness of Thymus. 

Some claim that there is a zone of vesicular resonance 
between the lower border of the dullness of the thymus and 
the upper border of the cardiac dullness; others, that they 
are continuous. This dullness is said to gradually diminish 
and to be gone at six years. The author has found it ex- 
tremely difficult to map out the normal thymus. When he 
finds dullness in this area it means to him enlargement of 
the thymus or some other pathological condition. 

Abdomen. The abdomen in infancy, on account of the 
large size of the liver and the small size of the pelvis, is shaped 



36 CASE HISTORIES IN PEDIATRICS. 

like an egg with the small end down. There is, therefore, no 
waist. The liver becomes relatively smaller as the child 
grows older, while the pelvis remains relatively small for 
several years. Its cavity is deep and the projection of the 
sacro- vertebral angle is less marked. The pelvis gradually 
increases in size, so that at puberty it presents, in both 
sexes, the characteristics of the adult male pelvis. It acquires 
its proper sexual characteristics after puberty. The shape 
of the abdomen changes with the changes in the relative size 
of the liver and pelvis. 

When the normal infant is lying on its back, the sides of 
the abdomen form nearly a straight line from the costal 
border to the pelvis. Bulging outward shows enlargement 
of the abdomen and laxness of its walls. The level of the 
abdomen in infancy and early childhood, when the child is 
lying on its back, is normally somewhat above that of the 
thorax. It is on a level with the thorax, or somewhat below 
it, in later childhood. The lower abdomen is normally more 
prominent in early childhood than in later childhood and 
adult life. The lower portion of the abdomen is especially 
prominent in chronic duodenal indigestion and when there 
is prolapse of the abdominal organs. In this condition the 
child stands with an exaggerated lumbar curve and the 
shoulders thrown back. 

The circumference of the abdomen at the navel is through- 
out infancy about the same as that of the chest. From this 
time on the chest is larger than the abdomen. The absolute 
circumference of the abdomen at the navel is of little impor- 
tance, because of the normal variations in the size of different 
children and in the relative size of the abdomen in different 
children. The relation between the size of the abdomen and 
that of the chest is of more importance, but not of much, 
unless the variation from the normal is marked, because the 
relation between the abdomen and chest varies so widely 
under normal conditions in dift'erent children. Comparative 
measurements of the abdomen in the same child are, however, 
often of very great importance. 

Enlargement of the abdomen is very common in infancy 
and early childhood as the result of disturbances of digestion. 



NORMAL DEVELOPMENT AND PHYSICAL EXAMINATION. 37 

Enlargement, while usually due to this cause, may, however, 
be due to more serious conditions, such as ascites and tuber- 
cular peritonitis. Enlargement of the abdomen in infancy 
should always suggest the possibility of sarcoma of the kidney 
as its cause. The signs of free fluid in the abdomen are the 
same throughout infancy and childhood as in later life. It 
is very easy, however, in infants and young children, when 
the abdominal walls are lax, to mistake liquid feces in the 
intestines for fluid in the peritoneal cavity, because under 
these conditions the liquid feces gravitate to the dependent 
portions of the abdomen. The presence or absence of a small 
amount of free fluid in the peritoneal cavity can often be 
determined, if the patient is an infant or young child, by 
holding it up with the face downward and percussing from 
underneath. The fluid, under these circumstances, will 
gravitate to the region of the navel. It must not be forgotten 
that both general and localized enlargements of the abdomen 
may be due to paralysis of the abdominal muscles. 

The sunken abdomen is almost invariably due to lack of 
intestinal contents. It may, however, be due to contraction 
of the intestines, as in colitis. Contraction of the intestine 
from lead colic and hysteria is practically never seen in child- 
hood. The abdomen is often sunken in meningitis. If it is, 
the depression is almost invariably due to the lack of intes- 
tinal contents, not to spasm of the abdominal muscles. 

Spasm of the abdominal muscles is of the same significance 
in infancy and childhood as in later life. It is impossible, 
however, to determine whether spasm is present or not if 
the child is crying. It must be quieted in some way, there- 
fore, if there is any possibility of the presence of some disease 
of the abdomen likely to be complicated by spasm. 

Diastasis of the recti muscles is not at all uncommon in 
thin babies and in those whose abdomen is enlarged. It is 
much more common above than below the navel. It almost 
never persists into later childhood. 

Epigastric herniae are not at all rare in infancy and early 
childhood. They rarely disappear spontaneously. 

Navel. The level of the navel is usually for a short time 
after the separation of the cord that of the abdomen. The 



38 CASE HISTORIES IN PEDIATRICS. 

navel soon puckers in, however, forming a depression. 
Granulomata, accompanied by a thin purulent discharge, 
are common at this time. It is important not to confuse 
them with the so-called "mucous polyp," which is a pro- 
trusion of the mucous membrane of the intestine. The dis- 
charge in this condition is thin and serous. A fecal discharge 
from the navel at this time means patency of Meckel's 
diverticulum, while a discharge of urine means patency of 
the urachus. Hemorrhage from the navel is not at all 
uncommon in the first week after birth, and is usually a 
manifestation of hemorrhagic disease of the new-born. 
Inflammation in or about the navel, as the result of infection 
of the skin or of the vessels, is not infrequent. It must not 
be forgotten that infection through the vessels may occur 
without any superficial inflammation. 

Umbilical hernia is not infrequent in infancy. 

Stomach. The empty stomach is completely covered by 
the liver during infancy and early childhood. Even when 
filled, it extends but a short distance into the triangle formed 
by the edge of the liver and the left costal border. The 
transverse colon passes in front of it at this age. Percussion 
of the stomach is extremely difficult and the results obtained 
are unreliable. It is safe to say, however, that under normal 
conditions the lower border never extends to the navel. The 
boundaries of the stomach in late childhood are the same as 
in adult life. 

The Pylorus is situated in infancy about midway between 
the tip of the ensiform and the navel in the median line or a 
little to the right. It is covered by the liver. It is not 
palpable when normal. If enlargement of the pylorus is 
suspected, the examination should be made both when the 
stomach is full and when it is empty, and with the abdominal 
walls relaxed. Relaxation of the walls can usually be easily 
obtained by making the child vomit or by washing out the 
stomach. Visible peristalsis is often present when there is 
stenosis or spasm of the pylorus. It is, of course, not present 
unless the stomach is full. If it does not appear after filling 
the stomach, the epigastrium should be flicked with a towel 
or the finger or rubbed with a piece of ice. 



NORMAL DEVELOPMENT AND PHYSICAL EXAMINATION. 39 

Gastric Capacity. The measurements ordinarily given for 
the gastric capacity at different ages are practically useless, 
because those based on experiments on the cadaver are 
obtained under abnormal conditions, while those based on 
the amount of food taken at a feeding neglect the fact that 
the pylorus opens and lets food through, even while it is being 
taken. It is safe to say, however, that the capacity of the 
stomach at birth is approximately one ounce. It is also true 
that the growth of the stomach is very rapid in the first three 
months, slow in the second three months, and more rapid in 
the fourth quarter than in the third. 

Breast fed babies of the same age take in a general way 
about the same amount of food in twenty-four hours, but 
the amount taken at individual feedings varies tremendously 
according to the appetite at the time and the interval between 
the feedings. While these facts are true, experience shows, 
nevertheless, that artificially fed babies, if fed at regular 
intervals, take, on an average, about the following amounts: 

Three months, 4 ounces (120 cc.) 

Six months, 6 ounces (180 cc.) 

Nine months, 8 ounces (240 cc.) 

One year, 9 to 10 ounces (270 to 300 cc.) 

Colon. The coecum, in infancy and early childhood, lies 
wholly or in part between horizontal lines drawn parallel with 
the crest of the ilium and the anterior, superior spine. It 
gradually works downward, so that in later childhood it is in 
the adult position. This fact is of some importance in rela- 
tion to the probable location of the appendix at various ages. 
Owing to the high position of the coecum and the large liver, 
the ascending colon is relatively short in infancy and early 
childhood. The lower border of the transverse colon is, in 
infancy, just above the navel. It gradually gets higher, so 
that in late childhood it is about two-thirds of the distance 
from the ensiform to the navel. 

Rectum. The attachments of the rectum to the surround- 
ing structures do not extend as high up in the pelvis in infancy 
as later and the lower third is more vertical. These facts, 
taken in connection with the peculiar shape of the infantile 



40 CASE HISTORIES IN PEDIATRICS. 

pelvis, predispose to prolapse. Malformation of the rectum, 
at or above the anus, should always be looked for, if the 
newly-born infant does not pass meconium. 

Anus. Fissure of the anus is common in infancy and is 
usually overlooked unless the examination is careful and the 
folds are stretched. Hemorrhoids are rare at this age. 
Mucous patches may be found in this region at any age. 

Liver. The upper border of the liver flatness is, on account 
of the slightly higher position of the diaphragm in infancy, 
somewhat higher at this age than later. It is at the fifth rib 
in the right mammillary line, at the seventh in the mid- 
axillary and at the tenth in the scapular line. It gradually 
descends, reaching the adult position at about six years. The 
large size of the liver and the wide angle of the ribs in infancy 
more than counterbalance the higher position of the dia- 
phragm, so that the lower border of the liver extends below 
the costal border. It extends at this age from one cm. 
(f inch) to three cm. (i| inches) below the costal border in 
the mammillary line and from two cm. (f inch) to six cm. 
(2 J inches) below the tip of the ensiform. There are no exact 
data as to when the adult relations are attained. The liver 
is, however, usually not palpable in the mammillary line after 
three years, although it probably may be felt normally up to 
eight years. 

It is very difficult to percuss out the lower border of the 
liver in infancy and early childhood, because of the thinness 
of its edge. It is, on the other hand, very easy to palpate 
the lower border, since the abdominal wall is comparatively 
thin. Palpation, therefore, gives much more accurate results 
at this age than percussion. If there is any discrepancy in 
the results obtained by palpation and percussion, those 
obtained by palpation should always be accepted. It is 
important, on account of the thinness of the abdominal wall, 
not to palpate too deeply. It is very easy to miss the edge 
if too much force is used and the palpation is too deep. 
Striking palpation is of very little value at this age, ordinary 
palpation giving far better results. 

Gall Bladder. The examination* of the gall bladder is 
very unsatisfactory in infancy and early childhood. It is 



NORMAL DEVELOPMENT AND PHYSICAL EXAMINATION. 4I 

extremely difficult to determine whether it is enlarged or 
not. As a matter of fact, it very seldom is enlarged at this 
age. 

Spleen. The position of the spleen is the same at all ages. 
It lies between the ninth and eleventh ribs and the anterior 
border does not extend beyond the cos to-articular line, that 
is, the line drawn between the left sterno-clavicular articula- 
tion and the tip of the eleventh left rib. Percussion of the 
spleen is very difficult during the first few years of life, 
because of its small size. It is seldom more than five cm. 
(2 inches) long and three cm. (i| inches) wide at this time, 
being smaller more often than larger, while its thickness varies 
between one-half a cm. (A inch) and one and one-half cm. 
(f inch). The normal spleen is not palpable unless the 
abdominal wall is unusually thin and lax. It is easily pal- 
pable, however, in infancy and early childhood if enlarged, 
even if the enlargement is slight. It is wiser, therefore, to 
trust to palpation than to percussion at this age. It is safe 
to conclude that if the spleen is palpable it is enlarged and 
that if it is not palpable it is normal. It is important not to 
press in too deeply while palpating, as, on account of the 
thinness of the abdominal wall and the superficial position 
of the spleen, it is very easy to push it out of the way by deep 
palpation. 

Kidneys. The kidneys are proportionately much larger 
in infancy than in later life, the relation of the weight of the 
kidneys to that of the body being in the infant as i to 120 and 
in the adult as i to 240. The kidneys are lower in relation 
to the vertebrae and iliac crests in the infant than in the adult, 
partly because of their relatively large size and partly because 
of the relatively small lumbar spine. The right kidney is 
said to be situated somewhat lower than the left, but there is 
some doubt as to this point. The adult relations are attained 
by middle childhood. 

It is impossible to percuss out the normal kidney either in 
infancy or childhood. It is not possible to feel the normal 
kidney unless the patient is very thin, and then only occa- 
sionally. If the kidney is palpable, the presumption is, 
therefore, that it is in some way abnormal. 



42 CASE HISTORIES IN PEDIATRICS. 

Floating kidneys are very uncommon in either infancy or 
childhood, and, if present, are usually congenital in origin. 
Tumors of the kidney make their appearance in the lumbar 
region, in the side or in the antero-lateral portion of the 
abdomen. They do not move with respiration. The colon 
is in front of them. 

Bladder. On account of the small size of the pelvis, the 
relatively large size of the rectum and the greater obliqueness 
of the pelvis in infancy, almost the whole of the bladder lies, 
at this age, above the pubic crest. When the bladder is dis- 
tended, practically the whole of the distention is upward into 
the abdomen. The distended bladder is ovoid in shape, the 
larger end being downward. There is no marked fundus. 
The tendency is for the bladder, when distended, to lie close 
to the anterior abdominal wall. Very little of the anterior 
surface is covered by peritoneum. When the child begins 
to stand and walk, the weight of the urine gradually changes 
the shape of the bladder. The shape of the pelvis also 
changes, so that by middle childhood the relations of the 
bladder are essentially the same as in the adult. The bladder 
at birth holds from two to four drachms (7.5 cc. to 15 cc), 
while at six months its capacity is about one ounce (30 cc). 
It is impossible to give any figures as to its capacity after 
this time, because of its great distensibility. 

The relatively high position of the bladder in infancy and 
early childhood must always be borne in mind, as otherwise 
it is easy to mistake it for a new growth or for fluid in the 
peritoneal cavity. The bladder should always be emptied 
by a catheter in every instance in which there is a question 
of an abdominal tumor or of free fluid in the abdomen. 
Some very awkward mistakes will be avoided in this way. 

The groins should always be carefully examined, because 
hernia is common and hydrocele of the cord not uncommon 
in this region. Inguinal adenitis is also common. An in- 
completely descended testicle is not infrequently found in this 
region and sometimes a misplaced ovary. 

External Genitals. The routine examination of the new- 
born infant should always include that of the external 
genitals. The most common abnormalities are: in females, 



NORMAL DEVELOPMENT AND PHYSICAL EXAMINATION. 43 

more or less extensive adhesions of the nymphae; in males, 
failure of or partial descension of the testicles and hypospa- 
dias. The labia minora are relatively large in infancy and 
early childhood and project beyond the labia majora. The 
prepuce is normally adherent to the clitoris throughout 
infancy and probably even longer. A bloody discharge from 
the vagina, probably the result of local congestion during 
labor, is not uncommon during the first few days of life. It 
must not be confused with hemorrhage from the vagina, 
symptomatic of hemorrhagic disease of the new-born. 

The glans penis is almost invariably completely covered 
by the prepuce and in the vast majority of instances the 
prepuce and glans are bound together by light adhesions. 
This is the normal condition and is different from phimosis, 
which is the condition in which the prepuce is so narrowed 
that it cannot be retracted over the glans. 

Extremities. The infant begins to reach out and grasp 
things purposefully when three or four months old. It 
begins to creep at about nine months, stands with help at 
ten or eleven months and walks alone at about fifteen months. 
These are, of course, average figures. Many infants do these 
things earlier and many others are tardy about standing and 
walking. 

Deformities of Extremities. Deformities of the extremi- 
ties in infancy and early childhood are, in the vast majority 
of instances, due to rickets. The most common of these 
deformities is enlargement of the epiphyses at the wrists and 
ankles, the wrists being affected more often than the ankles. 
When both are affected, the enlargement is usually more 
marked in the wrists. It is important not to confuse these 
enlargements of the epiphyses due to rickets with the en- 
largements due to syphilis. The enlargements of rickets 
occur in the epiphysis and at the epiphyseal line, while the 
enlargements due to syphilis occur at the lower end of the 
diaphysis at its junction with the epiphyseal line. 

The next most common deformity of the extremities is 
bowing of the long bones. This occurs much more often in 
the lower than in the upper extremities and in them results 
in bow-legs and knock-knees. Knock-knees are, however, 



44 CASE HISTORIES IN PEDIATRICS. 

probably more often due to an overgrowth of the inner 
condyles of the femora than to bowing of the bones. The 
best method of examination as to the presence or absence 
of bow-legs and knock-knees is with the child on its back and 
the legs extended. It is important not to confuse the normal 
bowing of the legs in infancy with pathological bowing. The 
normal bowing is of two types: a slight outward bowing of 
the lower third of the tibiae, present during the first few months 
of life, and a general outward bowing of the legs, which 
persists through the first year and sometimes longer. This 
latter bowing is apparent rather than real and is due to the 
fact that at this age complete extension at the knees is rarely 
possible. Unless care is taken to avoid outward rotation 
of the thighs, the lines of the partly flexed legs are compared 
instead of the inside lines of the legs. These lines are, of 
course, bowed and are often the cause of an erroneous diag- 
nosis of bow-legs. 

The sabre-like deformity of the tibiae in syphilis is often 
confused with the similar deformity caused by rickets. The 
deformity due to rickets appears in infancy, while that due 
to syphilis develops between three and ten years. When 
due to syphilis, it is associated with other signs of syphilis; 
when due to rickets, with other signs of rickets. When due 
to syphilis, it is usually the only bony deformity; when due 
to rickets, it is always associated with other gross deformities 
of the bones. 

It is important to notice whether the legs are of the same 
length. This is most satisfactorily determined by extending 
the legs while the child lies on its back. If they are not of 
the same length, the discrepancy is due to an actual difference 
in size or to congenital dislocation of one hip. If the shorten- 
ing is due to congenital dislocation of the hip, the trochanter 
will be found above Nelaton's line, the line drawn from the 
anterior superior spine of the ilium to the tuberosity of the 
ischium on the same side. In congenital dislocation of the 
hip the leg can be pulled down into the normal position. 
Double congenital dislocation of the hip is very unusual, but 
does sometimes occur. It is always well, therefore, to 
determine whether or not the trochanters are in the proper 





Congenital dislocation of the hips. 



NOR^IAL DEVELOPMENT AND PHYSICAL EXAMINATION. 45 

position and whether the legs can be pulled down from their 
usual position. 

Size of Extremities. The circumference of the arms and 
legs on the two sides is normally alike during infancy and 
childhood. Differences in size, if they are present, are usually 
due to wasting on one side, not to hypertrophy. It is very 
important, in testing for differences in size, to measure both 
extremities in exactly the same place. This can only be done 
by taking the measurement at some fixed distance from some 
bony landmark on both sides. No attention should be paid 
to differences of less than one cm. (f-inch), because such 
differences are within the limits of error in measurement. 

The shafts of the bones should always be examined for 
swelling, tenderness and fractures. The contour of the 
joints should also be noted. In a general way, swelling and 
tenderness over the long bones in infancy are most often due 
to scurvy, next to periosteitis ; in childhood, to periosteitis. 
Acute swelling of the joints in infancy and early childhood is 
most often due to septic arthritis; in later childhood, to 
rheumatism. Chronic swelling of the joints at any age is 
most often due to tuberculosis; comparatively seldom to 
syphilis. 

Position of Extremities. Improper position of the extremi- 
ties may be due either to permanent contractures or to 
temporary spasm. It must be remembered that in early 
infancy and in emaciated infants there is a normal hyper- 
tonicity of the muscles, most marked in the flexors, which 
prevents the complete extension of the extremities. The 
results of this normal hypertonicity must not be mistaken for 
permanent contractures. It is important to notice the char- 
acter of temporary spasm; whether, for example, the hands 
and feet are in the position of tetany or the hands clenched. 

It is not safe to assume that there is no spasm because when 
the child is quiet the extremities are in the normal position. 
Passive motions of the extremities should always be made to 
determine whether there is or is not any spasm. If resistance 
is encountered, it must be determined whether it is due to 
voluntary opposition or involuntary spasm. It is also 
important to determine whether the spasm is due to pain or 



46 CASE HISTORIES IN PEDIATRICS. 

not. It is important to remember that the spasm in cerebral 
paralysis in early infancy is often first shown by opposition 
to abduction of the thighs. 

Paralysis. If the child is unconscious, the presence or 
absence of paralysis must be determined by the way in which 
the extremities drop when they are let fall and by the amount 
of resistance which is encountered on passive motion. If 
conscious, older children will attempt to make the various 
motions as directed. Infants, however, w^ill not do this. 
The power in the arms must be tested by offering them 
things to play with or showing them their bottle; that in 
the legs by tickling their feet or pricking them with a pin. 
It is important to distinguish failure to use the extremities, 
because of the pain which motion causes, from real paralysis. 

Knee-jerks. The response to tapping the ligamentum 
patellae normally varies widely in infancy. It is often very 
hard to elicit the knee-jerk in infancy, because of the baby's 
failure to relax. It cannot be determined, however, unless 
the leg is relaxed, and on this account great patience is often 
required. The best method of eliciting the knee-jerk in 
infancy is to place the hand under the lower part of the thigh 
when the baby lies on its back, lifting it a little from the bed. 
A response can sometimes be obtained if the angle of the leg 
on the thigh is varied, the ligament being tapped repeatedly 
as the knee is moved up and down. The knee-jerk is best 
elicited in childhood by having the child sit up with the leg 
hanging down, as in adult life. 

Abdominal Reflex. This reflex is very inconstant in 
infancy and early childhood. 

Cremasteric Reflex. This reflex is lively in infancy, but 
much less so during childhood. Neither the abdominal nor 
the cremasteric reflexes are of much importance, however, 
unless they are different on the two sides. 

Plantar Reflex. The plantar reflex in infancy is more often 
shown by extension than by flexion of the toes. Babinski's 
Phenomenon, which is the simultaneous extension of the big 
toe with flexion of the other toes when the sole of the foot 
is scratched, is, therefore, of no diagnostic importance in 
infancy. It is of the same value in childhood as in later life. 




Method of eliciting Knee-jerk in infancy. 




Kernig's sign. 








Neck sign. 



NORMAL DEVELOPMENT AND PHYSICAL EXAMINATION. 47 

Babinski's phenomenon shows some irritation or affection of 
the pyramidal tract. 

Kemig's Sign. Under normal conditions the leg can be 
extended on the thigh to an angle of 135° or more when the 
thigh is at a right angle with the trunk. Kernig's sign 
consists in the inability to extend the leg on the thigh, when 
it is at a right angle with the trunk, to as much as 135"^. This 
sign is best tested with the child lying on its back. It makes 
no difference whether the thigh is flexed to a right angle on 
the trunk and the attempt then made to extend the leg or the 
leg extended on the thigh, with the thigh extended, and the 
attempt then made to bring the thigh to a right angle with 
the trunk. Kernig's sign is an involuntary manifestation and 
may or may not be accompanied by pain. The physiological 
hypertonicity of young and emaciated infants may be mis- 
taken for Kernig's sign, if it is not borne in mind. Kernig's 
sign is strong, but not positive, proof of meningitis in infancy 
and early childhood. 

Neck Sign. Under normal conditions flexion of the head 
forw^ard, when the child is lying on its back, causes no motion 
of the extremities. Under certain conditions, however, 
passive flexion of the neck forward, while the child is lying 
flat on its back, the chest being held stationary, causes 
flexion of the legs at the hips and knees, but sometimes only 
at the hips. This sign is known as Brudzinski's neck sign. 
It is sometimes present on one side and not on the other. It 
is present in many cases of meningitis and is almost never 
found in any other condition. 

Contralateral Reflex. Under normal conditions passive 
flexion of one leg causes no motion on the other side. In 
meningitis, and sometimes in other conditions, passive flexion 
of one leg causes a concomitant reflex of the leg on the other 
side — the identical contralateral reflex. Sometimes, how- 
ever, the motion of the other leg is extension instead of 
flexion — the reciprocal contralateral reflex. 

Trousseau's Symptom. Pressure on the nerve trunks of 
an extremity normally causes no reaction. In the spasmo- 
philic diathesis, however, pressure on the nerve trunks of an 
extremity not only brings on the typical spasm of tetany in 



48 CASE HISTORIES IN PEDIATRICS. 

that extremity but also in the others. This reaction is known 
as Trousseau's symptom. 

Chvostek's Symptom or the Facial Phenomenon. Under 
normal conditions mechanical irritation of the facial nerve 
produces no contraction. In the spasmophilic diathesis, 
however, irritation of the facial nerve, either by striking it 
or rubbing something quickly across it, causes contraction 
of the facial muscles on that side, especially of those of the 
lips. 

Sensation. Sensation to touch and pain can be made out 
even in infancy, although it is not very active during the first 
few months. Sensation to differences in temperature cannot, 
of course, be determined until the child is old enough to know 
hot from cold and to talk. Sensation is, in general, the same 
throughout childhood as in adult life. 

Vasomotor Disturbances. Superficial vasomotor disturb- 
ances of the skin are not at all uncommon in infancy and 
childhood in many pathological conditions. The taches 
cerebrales, are, therefore, of no importance in the diagnosis 
of cerebral diseases. 

Lymph Nodes. Local enlargement of the lymph nodes is 
of the same significance throughout infancy and childhood 
as in adult life. General enlargement of the peripheral lymph 
nodes occurs in infancy, however, in all disturbances of 
nutrition. At this age, therefore, it does not point to tuber- 
culosis, syphilis or some blood disease. The epitrochlear 
and occipital lymph nodes are often enlarged in disturbances 
of nutrition. Enlargement of these glands, therefore, does 
not at this age point toward syphilis. General enlargement 
of the peripheral lymph nodes in later childhood is of the 
same significance as in adult life. It is important to re- 
member that there is no anatomical or physiological con- 
nection between the lymph nodes of the neck and those of 
the chest. 

The physical signs of enlargement of the tracheo-bronchial 
lymph nodes, while theoretically very definite, are practically 
very unreliable. The earliest, and probably most reliable, 
sign is the bronchial voice sound over the upper four or five 
dorsal spines, this normally not being heard below the seventh 



NORMAL DEVELOPMENT AND PHYSICAL EXAMINATION. 49 

cervical spine. When the enlargement is greater, the res- 
piration also is bronchial in this region. If the glands are 
much enlarged, they may cause dullness in the interscapular 
region and under the manubrium and upper portion of the 
gladiolus. This latter dullness may as well, however, be due 
to an enlarged or persistent thymus. Bronchial breathing 
between the scapulae is also a sign of bronchial adenopathy. 
Murmurs under the manubrium, which are louder when the 
head is extended, are often attributed to enlargement of the 
tracheo-bronchial lymph nodes. They are undoubtedly due 
to this cause in some instances, but, since they can be pro- 
duced in any baby by extending the head, are of no importance 
in diagnosis. If the lymph nodes are much enlarged, they 
may by pressure cause a difference in the amount of the 
respiratory sound on the two sides, distention of the cervical 
veins, edema of the face, atalectasis of the lung, hoarseness 
and aphonia. Expiratory dyspnea is also a sign of enlarge- 
ment of these nodes. 

Development of Faculties. It is often of great importance 
to determine whether or not a baby is normally developed 
mentally. This must be decided by comparing its develop- 
ment with that of the normal baby of the same age. To do 
this it is necessary to know what the normal baby should be 
able to do at a given age. Babies differ so much in their 
mental development under normal conditions, however, that 
it is impossible to give more than average figures. In a 
general way, the baby smiles at from four to five weeks, and 
laughs at from five to six months. He begins to notice 
objects at from six to eight weeks, and probably knows his 
mother or nurse from other people when about three months 
old. He shows signs of fear at six months, or even younger, 
and shows plainly his likes and dislikes at a year. He 
enunciates single words at from ten to twelve months, and 
forms short sentences by the middle or end of the second year. 
He makes purposeful gestures at eighteen months. He should 
control his sphincters by two years. This point is of com- 
paratively little value, however, as the development of the 
control of the sphincters depends very largely on the baby's 
training. 



50 CASE HISTORIES IN PEDIATRICS. 

Skin. The skin should always be examined for eruptions, 
ecchymoses, desquamation and scars. Its color should also 
be noticed. The color of the nails and of the mucous mem- 
branes is a far better index of the condition of the blood, 
however, than the color of the skin. It must not be forgotten 
that many pale children are pale because of the small size 
of the skin capillaries and the thickness of the skin, not 
because of anemia. 

Bluish or bluish-black spots in the sacral and gluteal 
regions occur in 90% of Asiatic children and in those with 
negro blood. They are known as Mongolian spots and are 
also sometimes seen in white children. They gradually 
disappear and are almost always gone before the close of 
infancy. They are due to a deposit of pigment in certain 
cells of the corium. They are, moreover, not a sign of an 
admixture of negro blood, but merely of the persistence, in 
a rudimentary form, of a functional layer of pigment cells 
in our ancestors, the monkeys. 

Three conditions of the skin which are liable to be confused 
are edema, sclerema and angioneurotic edema. Edema 
may occur at any age, appears first in the eyelids, on the 
dorsa of the feet and in dependent portions, is not hard, pits 
on pressure, is not associated with rigidity and is pale or 
waxen in color. Sclerema occurs in the new-born, or in very 
feeble infants. It usually develops first in the cheeks, back 
or posterior surfaces of the legs, but may appear anywhere, 
except in the prepuce, scrotum, palms and soles. It is hard, 
does not pit on pressure, is accompanied by rigidity of the 
extremities and is of a normal or slightly bluish color. An- 
gioneurotic edema may be general, but is usually circum- 
scribed. It may appear in any position. It is usually 
somewhat pinkish in color, does not pit on pressure and is 
often accompanied by itching. 

The function of the Sweat glands is usually not developed 
at birth. Babies ordinarily begin to perspire when they are 
from three to five weeks old. 

THE URINE. The Urine in the Newly-born. The first urine 
is acid, almost always clear and but little colored. During the 
first four or five days it is usually more or less cloudy from the 



NOR3HAL DEVELOPMENT AND PHYSICAL EXAMINATION. 5 1 

presence of epithelial cells from the urinary passages and uric 
acid crystals. The specific gravity averages about 1012. 
Small amounts of albumin are almost always present, but 
rarely last longer than ten days. The sediment always 
contains epithelial cells, various forms of uric acid crystals, 
and now and then hyaline casts. The amount of urine is 
small. It increases rather rapidly on the fourth day, 20 to 
50 cc. being passed in the first three days and about 1 00 cc. 
on the fourth day. It averages between 200 cc. and 300 cc. 
in the second week. 

The Urine in Infancy. The odor is slight, the color pale. 
It is usually clear, sometimes slightly opalescent and not 
infrequently turbid from mucus. Turbidity should always 
suggest the possibility of an infection of the urine with colon 
bacilli. If the turbidity is not cleared by heat, a micro- 
scopic examination should always be made. The reaction 
is feebly acid. The specific gravity varies from 1003 to 1008 
in the first six months, and from 1006 to 1012 up to two 
years. It does not contain albumin, and sugar is absent 
with the ordinary reagents. Sugar is not infrequently found 
in the urine of healthy infants during the first two months, 
and may be made to appear in the urine by increasing 
the amount ingested. According to Gr6sz, lactose appears 
in the urine when more than three or four grams per kilo 
of body weight are given, the limits of tolerance for other 
sugars being higher, that for glucose being five grams and 
that for maltose nearly eight grams per kilo. The sedi- 
ment is slight and consists entirely of cells. The amount 
of urine is relatively large, the infant passing from five to 
six times as much urine per kilo of weight as the adult. 
It varies between 200 cc. and 500 cc. from the first to the 
seventh month, and between 250 cc. and 600 cc. up to 
two years. The characteristics of the urine in childhood 
are essentially the same as in the adult. The quantity, 
however, is three or four times as large per kilo of weight 
as in the adult. It is impossible, however, to give anything 
more than approximate figures as to the amount passed 
at different ages, because of the variations dependent on the 
amount of fluid ingested. Holt has combined the figures 



52 CASE HISTORIES IN PEDIATRICS. 

of a considerable number of observers and arrived at the 

following results: 

Two to five years, 500- 800 cc. 

Five to eight years, 600-1200 cc. 

Eight to fourteen years, 1000- 1500 cc. 

The specific gravity is on the whole somewhat lower in 
childhood than in adult life. It is impossible to give any 
figures as to the specific gravity at different ages, because 
of the normal variations according to the amount of fluid 
ingested. 

The Blood. Hemoglobin. The percentage of hemoglobin 
varies between 100 and 125 during the first three or four days 
of life. It then rapidly drops to the minimum of about 60% 
in three weeks, after which it gradually rises to about 70% 
at six months. It remains at this point during the rest of 
the first two years, after which it slowly rises, reaching the 
adult standard at about six years. The normal variations 
in the percentage of hemoglobin in different children and at 
different times in the same child are very marked. The 
percentage of hemoglobin averages somewhat higher in boys 
than in girls. 

Red Corpuscles. The number of red corpuscles per cubic 
mm. during the first two or three days of life varies between 
6,000,000 and 7,500,000. The large number of red cells at 
this time is probably due to a combination of loss of fluid 
and starvation. The number of red cells then rapidly falls 
to the normal infantile limit, which it reaches at about two 
weeks. The number of cells during infancy ranges between 
5,500,000 and 6,000,000. The number gradually diminishes 
during early childhood, reaching the adult standard at 
approximately six years. 

Variations in the size and shape of the red cells develop 
much more quickly in infants and in young children than in 
older children and adults. Nucleated red cells are normally 
present in small numbers during the first six days. They 
appear with less provocation during infancy than later. 

White Corpuscles. There is a marked increase in the 
number of leucocytes during the first few days, this increase 



NORMAL DEVELOPMENT AND PHYSICAL EXAMINATION. 53 

sometimes reaching as high as 36,000. The number rapidly 
drops to from 12,000 to 14,000, where it remains during the 
first six months. The normal limits during the rest of 
infancy are between 10,000 and 12,000 per cubic mm. The 
number of leucocytes from this time on is approximately the 
same as in adults. 

The digestive leucocytosis is very inconstant and irregular 
in infancy. Leucocytosis develops more quickly and is 
usually more marked in infants and young children than in 
older children and adults. The type of leucocytosis is also 
less constant at this age, a considerable increase in the number 
of mononuclear cells being not uncommon. The percentage 
of polynuclear cells is high at birth, rises during the first 
twenty-four hours to 70% or a little more, then quickly drops 
to the normal infantile relation at the end of the first week 
or ten days. The relations of the different normal forms of 
leucocytes throughout infancy are roughly as follows: 



Small mononuclear. 


40% to 50% 


Large mononuclear and transitional 




forms. 


10% 


Polynuclear neutrophiles, 


35% to 45% 


Eosinophiles, 


1% to 5% 


Mast cells. 


1% 



The mononuclear cells vary much, not only in the size of 
the cell as a whole but also in the size of the nucleus and in 
the amoxmt of protoplasm. The percentages of the large 
mononuclear and transitional forms and of the eosinophiles 
remain about the same to middle childhood, while that of the 
small mononuclear cells gradually diminishes and that of the 
polynuclear neutrophiles increases until the adult relations are 
reached at from five to six years. 

Myelocytes are not normally present in the infant's blood. 
They appear, however, on relatively slight provocation and 
sometimes in considerable numbers. Their presence is, 
therefore, of much less significance at this age than later, 
a percentage of from five to six, or even more, not being very 
unusual at this age in secondary anemia. 

An increase in the number of eosinophilic cells is not 



54 CASE HISTORIES IN PEDIATRICS. 

uncommon in infancy and early childhood and seems to be 
of but little significance. The percentage may be as high 
as ten without any evident cause. A high percentage of 
eosinophils should, however, always suggest the presence 
of intestinal parasites. 

In considering the blood changes in infancy and early child- 
hood certain points must be borne in mind: Blood changes 
develop more easily and more frequently as the result of 
morbid conditions and diseases than in older children and 
adults. All the changes seen in later life as the result of 
disease are aggravated in infancy. The tendency is always 
to revert to a younger or to the foetal type of blood. As the 
result of the tendency to aggravation of changes and to 
reversion to a younger type of blood, the red corpuscles show 
much greater variety in size and shape and many more 
nucleated forms are seen than under similar pathologic con- 
ditions in the older child and adult. In general, the most 
characteristic features of all the blood diseases of infancy are 
the relatively low percentage of hemoglobin, the relatively 
large number of non-granular cells and the marked mor- 
phological changes in the red corpuscles. 

The Stools in Infancy. The characteristics of the stools in 
infancy are so different from those of children after they have 
begun to take an ordinary mixed diet that they deserve 
special description. The characteristics of the stools of 
children are the same as in the adult. 

The stools differ normally according to whether the infant 
is taking human milk or cows' milk, and whether starches or 
other carbohydrates are added to the cows' milk. 

The Stools of Breast-fed Infants. The breast-fed infant 
has, during the first few weeks or months of life, three or four 
movements daily of the consistency of pea soup, of a peculiar 
golden-yellow color, with a slightly sour or aromatic odor, and 
with a slightly acid reaction. The number of stools diminishes 
later to two or three in the twenty-four hours and the con- 
sistency becomes more salve-like, the other characteristics 
remaining the same. The golden-yellow color is due to 
bilirubin, which passes unchanged through the intestinal 
tract because of the rapidity of the passage, the relatively 



NORMAL DEVELOPMENT AND PHYSICAL EXAMINATION. 55 

low proteid content of the milk and the low reducing power 
of the infant's intestine. The odor is due to a combination 
of lactic and fatty acids. The acid reaction is due to the 
relative excess of fat over proteid in the milk. 

It is not uncommon, even when babies are doing well on 
the breast, for them to have a larger number of stools of 
diminished consistency and of a brownish color. In such 
instances examination of the breast milk usually shows that 
the proteids are high. It is also not unusual to find numer- 
ous soft, fine curds and sometimes mucus in the stools of 
healthy breast-fed babies. While such stools are undoubtedly 
abnormal, it is unwise to pay too much attention to them 
if the baby is gaining and seems well. 

The Stools of Infants fed on Cows' Milk. Infants that are 
thriving on cows' milk mixtures have, as a rule, fewer move- 
ments in the twenty-four hours than breast-fed babies and 
these movements are of firmer consistency. Slight con- 
stipation is not uncommon after the first few months and is 
not of pathological significance. The color of the stools is a 
lighter yellow, probably because of the relatively larger 
amount of proteid, and because some of the bilirubin is 
converted into hydrobilirubin. When the relative propor- 
tions of fat and proteids in the mixtures are approximately 
those of breast milk, the odor and reaction of the stools are 
essentially the same as when the infant is taking breast milk. 
When infants are given whole cows' milk or simple dilutions 
of cows' milk, so that the proteids are equal to or greater than 
the fat, the odor is slightly modified toward the fecal or cheesy 
because of the action of bacteria on the casein. The reaction 
becomes alkaline for the same reason. 

Skimmed Milk Mixtures. When infants are fed on 
skimmed milk or on mixtures very low in fat and high in 
proteids, the stools have a slightly brownish-yellow color, a 
slightly cheesy or foul odor, and a strongly alkaline reaction 
because of the longer stay of the casein in the intestine and 
the consequently greater opportunity for bacterial action 
and for the change of bilirubin to hydrobilirubin. In some 
instances the stools have a peculiar salve-like appearance like 
those from buttermilk. 



56 CASE HISTORIES IN PEDIATRICS. 

Whey and Whey Mixttires. When infants are fed on whey 

or whey mixtures low in fat, the stools have essentially the 
same characteristics as those from skimmed milk, except that 
they are usually browner. 

Starch Mixtures. When starch is added to cows' milk 
mixtures the color of the stools becomes distinctly brownish 
and the reaction tends toward the acid. The odor is more 
aromatic. Most starch flours contain small brownish specks 
which are the remains of the husks. These specks pass 
through the gastrointestinal tract unaffected and appear in 
the stools. 

Malt Sugar Mixtures. The addition of malt sugar to cows' 
milk mixtures changes the color of the stools to a distinct 
brown, tends to make the reaction acid and to increase the 
acidity of the odor. When malt sugar or the malted foods 
are given without milk the stools are dark brown, sticky, 
acrid in odor and acid in reaction. 

Buttermilk and Buttermilk Mixtures. The stools of in- 
fants fed on buttermilk and buttermilk mixtures are of a 
peculiar shiny, salve-like appearance, grayish-brown in color, 
alkaline in reaction and have a very characteristic acrid odor. 

Animal Food. When beef -juice or broth is added to the 
infant's diet the color of the stools is changed to brown, while 
the odor becomes fecal and the reaction alkaline from the 
action of bacteria on the proteids. 

The Starvation Stool. The starvation stool is made up of 
bile, the intestinal secretions and bacteria and resembles the 
meconium. It is usually small, sometimes constipated, 
sometimes loose, brownish or brownish-green in color and 
has, as a rule, a stale odor like that of starch or paste. In 
some cases it has the odor of acetic acid as the result of the 
action of microorganisms. 

Reaction of the Stools. The reaction of the normal stool 
depends on the relation between the fat and proteids in the 
food. When there is a relative excess of fat the reaction is 
acid; when there is a relative excess of proteid the reaction 
is alkaline, the reaction depending, in the one case on the 
products of the decomposition of fat, in the other on the 
products of the decomposition of proteids. The carbo- 



NORMAL DEVELOPMENT AND PHYSICAL EXAMINATION. 57 

hydrates have no effect on the reaction of the normal stool. 
When the carbohydrates are in excess, or when there is 
fermentation of the carbohydrates as the result of bacterial 
action, the acidity of the stools is markedly increased. 
Stools which irritate the buttocks are invariably acid in 
reaction, and in most instances this excessive acidity is due 
to the decomposition of carbohydrates. Frothy stools are 
usually acid in reaction, and due to the same cause, but some- 
times the frothiness is caused by gases formed during the 
decomposition of proteids. The reaction of the stools is, 
however, of comparatively little importance from the clinical 
side. It is best tested by placing wet red or blue litmus paper 
on, not in, the stool. 

Odor of the Stools. The odor of the stools depends on the 
composition of the food, the rapidity of the absorption of the 
products of digestion and the degree of the bacterial activity. 
The fats give the odor of butyric or lactic acid to the stools. 
The carbohydrates, if thoroughly utilized, do not affect the 
odor; if not utilized, they give the odors of lactic, acetic or 
succinic acids. The proteids give cheesy odors of various 
sorts, sometimes those of skatol, indol and phenol. 

The odor of the normal stool and the influence of variations 
in the diet upon it have already been mentioned. The stools 
of fat indigestion have a strong odor of butyric acid, those of 
proteid indigestion various cheesy or putrefactive odors as 
the result of the decomposition of the proteids by bacteria. 
When several elements of the food are improperly digested 
the odor is a combination of those resulting from the decom- 
position of the various elements. The stools of cholera 
infantum are almost odorless. Stools composed almost 
entirely of mucus have a peculiar aromatic odor, resembling 
that of wet hay. When there are deep ulcerative or gan- 
grenous processes in the intestine, the stools have a putre- 
factive or gangrenous odor. 

Color of the Stools. The normal variations in the color 
of the stools according to the composition of the food have 
already been mentioned. Abnormalities in the color are very 
common. The color of the stool must not be judged from 
the outside, as it may change very rapidly from drying and 



58 CASE HISTORIES IN PEDIATRICS. 

exposure to the air. The stool must be broken up or smoothed 
out and the inside examined. 

Green. The most common abnormal color is green. The 
shade of green may vary from a very delicate light grass- 
green to a dark spinach green. In a general way, the darker 
the green the greater its significance. A very light grass- 
green color in a stool which is othervvise normal is of no 
practical importance. The change from yellow to green after 
the stool is passed is not abnormal. The green color is, in 
the vast majority of instances, due to the change of bilirubin 
to biliverdin. There is much doubt as to the cause of this 
change. It is probable that it m.ay be due to either excessive 
acidity or alkalinity of the intestinal contents or to the pres- 
ence of some oxidizing ferment. The green color is not 
characteristic of any special type of disease. In some in- 
stances it is due to the action of the bacillus pyocyaneus. 
If it is due to bacterial action, the addition of nitric acid 
decolorizes the stool. If it is due to biliverdin, the addition 
of nitric acid gives the characteristic colors of Gmelin's 
test. 

Gray. The next most common abnormal color is gray. 
This is due, as a rule, to the absence of bile and the presence 
of some form of fat in the stool. It must be remembered, 
however, that there may be bile in the stool even when it is 
gray, the bile pigment being in the form of the colorless 
leucohydrobilirubin. It is never safe, therefore, to conclude 
that there is no bile in the stool without a chemical examina- 
tion. The easiest and most satisfactory test is that with 
corrosive sublimate. When the stools are gray at birth, or 
become so within a few days after birth, the lesion is usually 
a congenital obliteration of the bile ducts. When the gray 
color appears later, and especially when it is associated with 
large amounts of mucus, the trouble is usually in the duo- 
denum. 

White. The white stools are due to the presence of 
undigested fat in the form of soaps. These may be soft, 
looking much like curdled milk, or, more often, hard and 
dry, resembling the stools of a dog which has been eating 
bones. 



NORMAL DEVELOPMENT AND PHYSICAL EXAMINATION. 59 

Black. The black stool, while in rare instances due to the 
presence of changed blood, is usually due to the action of 
some drug, ordinarily bismuth, sometimes iron. 

It is very common to see a pink stain on the diapers about 
a stool which is otherwise normal, or nearly so. This pink 
stain is of no especial significance and is due to some unknown 
change in the bile pigment. 

Abnormal Constituents. Curds, The most common ab- 
normal constituents are curds. There are two kinds of curds, 
one primarily composed of casein, the other composed mainly 
of fat, mostly in the form of fatty acids and soaps. The 
small amount of fat in the casein curds and the small amount 
of proteid in the fat curds are merely incidents. The casein 
curds vary in size from that of a bean to that of a pecan nut. 
They are usually white, sometimes yellow, in color. They 
are firm and tough, cannot be broken up by pressure and sink 
in water. When placed in formalin they become as hard as 
rocks. They are insoluble in ether. The fat curds are small, 
varying in size from that of a pinhead to that of a small pea. 
They vary in color from white to yellow or green, according 
to the general color of the movement. They are easily 
broken up by pressure, and, when shaken up in water, tend 
to remain in suspension. They are soluble in ether to a 
considerable extent after acidification and are unaffected by 
formalin. 

Mucus, Mucus can be detected in small amounts under 
the microscope in the majority of normal stools, and is almost 
invariably present in abnormal stools. It is never present 
macroscopically in normal stools, but is very common in the 
abnormal. It does not denote any special form of disease, 
merely an excessive secretion of the mucous glands of the 
intestine from some cause. When thoroughly mixed through- 
out the stool it usually comes from the small intestine ; when 
in combination with a clay-colored stool, from the duodenum; 
when on the outside of a constipated stool, from the rectum. 
Stools composed mainly or entirely of mucus and blood 
indicate either severe inflammation of the colon or intussus- 
ception. Undigested starch is often mistaken for mucus. 
They can be distinguished by the addition of some preparation 



6o CASE HISTORIES IN PEDIATRICS. 

of iodine, which stains the starch blue, but does not affect the 
mucus. The suspected material should be taken off the 
diaper in order to avoid possible confusion from the presence 
of starch on the diaper. 

Blood. Blood on the outside of a constipated stool 
indicates a crack of the anus. Blood mixed with mucus 
indicates either severe inflammation of the large intestine or 
intussusception. Blood in infancy is seldom due to hemor- 
rhoids, i 

Pus. Pus indicates severe inflammation of the large 
intestine. It is usually not present early in the disease, but 
appears later. When the infants survive the acute stage it 
persists into convalescence. Pus can be found with the 
microscope in nearly every case of inflammation of the 
colon, but is of no special significance unless visible macro- 
scopically. 

Membrane. Membrane indicates very severe inflammation 
of the large intestine and is rarely seen, the patients usually 
dying before membrane appears in the stools. 

Other abnormal constituents are undigested masses of food, 
foreign bodies which have been swallowed, and worms. 

Microscopic Examination of the Stools. The macroscopic 
examination of the stools affords data sufliciently reliable for 
clinical work in the great majority of instances. It may, 
however, lead to erroneous conclusions, especially with regard 
to the amount of fat and undigested starch. Fatty and 
starchy stools sometimes appear perfectly normal macro- 
scopically, and only microscopical examination will prevent 
mistakes. It is advisable, therefore, in all but the plainest 
cases, to examine the stools microscopically as well as macro- 
scopically. The microscopical examination of the stools is 
not a diflicult procedure and can be carried out in ten minutes 
or less by anyone accustomed to it. 

The feces, if hard, are first rubbed up with a little water. 
Otherwise they are thoroughly mixed, and three different 
portions examined. The first is examined in the fresh con- 
dition. In this portion any undigested tissues or pathological 
elements, such as blood, pus and eggs of parasites, can be 
differentiated. A preliminary estimation of the amount of 



NORMAL DEVELOPMENT AND PHYSICAL EXAMINATION. 6l 

neutral fat, fatty acids, soaps and starches can also be 
made. 

The second portion is stained with Lugol's solution (iodine, 
2; potassium iodide, 4; distilled water, 100) and examined for 
starch. The starch granules stain blue or violet. Certain 
microbes also stain blue. These, the so-called iodophilic 
bacteria, are associated with faulty carbohydrate digestion, 
and, when found alone without other symptoms, are sugges- 
tive of an early disturbance in the digestion of the carbo- 
hydrates. Before concluding that undigested starch is 
present, all possibility of contamination with baby powders 
must be eliminated. 

The third portion is stained with a saturated alcoholic 
solution of Sudan III. The neutral fat drops and fatty acid 
crystals stain red. Soap crystals do not stain with Sudan III. 
After this specimen is examined and the microscopic picture 
is clear, a drop of glacial acetic acid is allowed to run under 
the coverglass, is thoroughly mixed in, and then heated until 
it begins to boil. This process turns the soap into neutral 
fat and fatty acid which will appear as large stained drops 
and upon cooling crystallize. They usually retain the red 
stain. Any increase in the amount of fat after the addition of 
acetic acid indicates the presence of a corresponding amount 
of soaps. If there are any fat drops visible after the addition 
of Sudan III and before the addition of acetic acid, another 
specimen should be stained with a dilute solution of carbol- 
fuchsin (carbolfuchsin sol., i; water, 4 or 5). With this 
solution the neutral fat is not stained, while the fatty acids 
are stained a deep red and the soaps a dull rose-red. Without 
this stain it is impossible to distinguish neutral fat from fatty 
acids. An excess of neutral fat indicates that the digestion 
of fat is not carried on normally; an excess of fatty acids 
and soaps, that the digestion is normal, but assimilation is 
abnormal. 

It is well to examine the specimen first with a low-power 
objective and later with a No. 7 objective in order to bring 
out the detailed structure. 

Bacteriologic Examination of the Stools. Our knowledge 
of the bacteriology of the disturbances of digestion and of 



62 CASE HISTORIES IN PEDIATRICS. 

the various inflammatory diseases of the intestine is so 
limited at present that no conclusidhs of clinical impor- 
tance can be drawn from the microscopic examination of 
the stools, the only exception being, possibly, the presence 
of large numbers of iodophilic bacteria, which, as already 
stated, point to disturbance of the digestion of the carbo- 
hydrates. 




Gown for premature infant. 




Premature infant in gown. 



SECTION II. 
DISEASES OF THE NEW-BORN. 

CASE I. Ruth S. was delivered at 6 a.m., April 6, by high 
forceps, after a labor lasting twelve hours. The operation 
was not a difficult one. She w^as expected May 9. She 
gasped at once and breathed immediately, but did not cry. 
She passed both urine and meconium soon after she was 
born. Her parents were healthy, but frail. There was no 
known cause for the premature labor. She w^as seen at 
7.30 A.M. 

Physical Examination. She was small but well nourished. 
Her color was good, her skin clear and the surface of the body 
warm. The heart w^as normal and the lungs fully expanded. 
The lower border of the liver was palpable three cm. below 
the costal border in the nipple line. The spleen was not 
palpable. There were no deformities. She weighed five 
pounds. 

Diagnosis. The diagnosis is, of course. Prematurity. 
Whatever may be the cause of the prematurity, it is certainly 
not syphilis. 

Prognosis. The prognosis should always be guarded in 
premature babies. They ought not to be considered out of 
danger until they are thriving under normal conditions. 
Her chances are, however, better than the average, because 
she is only a month premature, weighs five pounds, was born 
after a short and easy labor and is not syphilitic. 

Treatment. She ought not to be bathed, but should be 
anointed with olive oil. She should be oiled in her crib every 
other day. This will gradually clean the skin and keep it 
in good condition. She should not be dressed, but should 
be wrapped in absorbent cotton, or, better, in a quilted gown 
with a hood. The gown is made by quilting cotton between 
two layers of cheesecloth. This protects the baby as well as 

63 



64 CASE HISTORIES IN PEDIATRICS. 

cotton alone, and makes the care much easier. Absorbent 
cotton should be used at first instead of a diaper. 

She should be placed in a padded bassinette or basket, the 
temperature of which should be kept at 90° F., by electric 
heating pads or hot water bags or bottles. The thermometer 
by which the temperature of the basket is regulated should 
be fastened to the front of the gown. Her rectal tempera- 
ture should be taken two or three times daily. If it is above 
99.5° F., the temperature of the basket should be lowered; 
if it is below normal, it should be raised. The temperature 
of the room should be kept at 80° F. The air of the room 
must at the same time, however, be kept fresh. The ther- 
mometer by which the temperature of the room is regulated 
must be hung near the basket, not on the wall many feet from 
the baby. A sunny room with a fireplace, in which there is 
a fire, is the best. A padded basket is much preferable to 
an incubator, because an incubator does not provide a suffi- 
cient supply of fresh air, and because the temperature of the 
air which the baby has to breathe is too high. The baby*s 
vitality and its resistance to infection are lowered by the lack 
of fresh air. The lack of fresh air increases the liability of 
infection, and bacteria grow most luxuriantly at the tempera- 
ture at which the incubator is usually kept. 

She should be given a teaspoonful of warm water every two 
hours until to-morrow morning. She ought not to be put to 
the breast then, because she is not strong enough to suck well, 
is not vigorous enough to be handled and is liable to be 
chilled by the exposure consequent to being taken from her 
basket. It is even more important, on account of their 
undeveloped powers of digestion and absorption, for pre- 
mature babies than for full-term babies to have breast-milk. 
Their chances of survival are much better on breast-milk 
than on any modification of cows' milk. She should, there- 
fore, be given a drachm of a mixture of one part of breast- 
milk and three parts of water every two hours, day and night. 
If her mother has no milk, a wet nurse should be procured. 
If breast-milk is not obtainable, she may be given instead a 
modified milk containing 1% of fat, 5% of milk sugar, 0.25% 
of whey proteids and 0.25% of casein. This amount of food 



DISEASES OF THE NEW-BORN. 65 

is entirely inadequate to cover her caloric needs. There is 
great danger, however, of disturbing her digestion, if too 
strong a mixture or too large a quantity is given at first, and 
it will be very difficult to correct it, if it is disturbed. If she 
takes and digests her food well, the strength and the amount 
at a feeding should be rapidly increased, changes being made 
every day, or even twice a day, if necessary. It must be 
remembered that premature babies, on account of their small 
size and their imperfect metabolism, require more calories 
per kilo than full-term babies, and that, therefore, it is very 
important to increase the strength and amount of her food 
as fast as is possible without disturbing her digestion. She 
is too small to take an ordinary nipple well and probably 
too feeble to suck vigorously. The milk should, therefore, 
be given to her in a **Breck Feeder," which is far better 
than either a spoon or a dropper. The "Breck Feeder" is a 
graduated glass tube open at both ends. On the smaller 
end is a nipple, about the size of the rubber of a medicine 
dropper. This is perforated and goes into her mouth. On 
the other end is a large finger cot. By squeezing the finger 
cot the milk can be forced into her mouth and efforts at 
sucking be aided or induced. 

She must not be handled any more than is absolutely 
necessary. No one should be allowed to see her except those 
who are taking care of her. It is not necessary to darken the 
room or to be especially careful about noise, because light 
and noise will not disturb her at present. 

She does not require any stimulation. 



66 CASE HISTORIES IN PEDIATRICS.' 

CASE 2. John M., the first child of healthy parents, was 
born at full term after an instrumental labor. He was normal 
at birth, except for a tumor in the neck. This tumor had 
not increased in size. He had never been properly fed, had 
had more or less disturbance of the digestion from the first 
and had not gained in weight. He was admitted to the 
Floating Hospital when six weeks old. 

Physical Examination. He was fairly developed and 
nourished. The hair was sparse. The anterior fontanelle 
was three cm. in diameter and level. The posterior fon- 
tanelle was still open. The pupils were equal and reacted to 
light. The cervical spine was normal. The throat was 
normal, as were the heart and lungs. The abdomen was full, 
soft and tympanitic. The lower border of the liver was just 
palpable in the nipple line, the upper border of dullness being 
at the fifth rib in the same line. The spleen was not palpable. 
The extremities showed nothing abnormal. There was no 
spasm or paralysis. The knee-jerks were equal and normal. 
Kernig's sign was absent. There was a slight general 
enlargement of the peripheral lymph nodes. There was a 
mass, the size of a small orange, in the left side of the neck. 
The location is best shown in the accompanying photograph. 
It was covered with normal skin and was neither hot nor 
tender. Pressure on it caused no discomfort or diminution 
in size. It was rounded, but had a definite and relatively 
small base. It was somewhat fluctuant and evidently con- 
tained fluid. The fluctuation was not as marked, however, 
as would have been expected if the fluid was contained in a 
single cavity. Several small masses could be felt indis- 
tinctly, as well as a number of bands running through it. 
The rectal temperature was 99.2° F.; the pulse, 126; the 
respiration, 30. 

Diagnosis. The absence of heat, redness and tenderness 
and the normal temperature show that the tumor cannot be 
inflammatory in origin, even if this possibility was not 
excluded by the fact that it was present at birth. The 
absence of any defect in the cervical spine, the position of 
the tumor, the absence of all signs of involvement of the 
spinal cord and the fact that pressure on the tumor causes 




John M. Case 2. 



DISEASES OF THE NEW-BORN. 67 

no discomfort or diminution in its size exclude a spinal 
meningocele. The position of the tumor, posteriorly to the 
sternocleidomastoid muscle, and the fact that it is evidently 
multilocular rule out a branchial cyst. The only other con- 
genital tumor which occurs in this position is the cystic 
hygroma. This tumor is situated in the usual position of 
these tumors, contains fluid and is multilocular. It corre- 
sponds, therefore, in all its characteristics to those of a 
Cystic Hygroma of the Neck, and undoubtedly is one. 

Prognosis. The tumor will certainly not diminish in size 
and is not likely to grow any larger. It may, however, 
become infected and suppurate. It is in no way dangerous 
to life, but, unless removed, will cause much discomfort and 
inconvenience. 

Treatment. The tumor must, of course, be eventually 
removed. It will be wise, however, to delay until the baby 
is older and stronger, because these tumors usually have 
diverticulae which extend deep into the neck, the removal 
of which often makes the operation a long and serious one. 



68 CASE HISTORIES IN PEDIATRICS. 

CASE 3. Mary C, the first child of healthy parents, was 
born at full term, after a normal labor, at 9 p.m., Aug. 21. 
She appeared normal at birth, except that her abdomen was 
rather large, and weighed nine pounds. She passed no meco- 
nium either during or after the labor. She began to vomit a 
yellowish-green material soon after birth. The vomiting was 
not explosive. It was, in fact, more like regurgitation than 
vomiting, the vomitus often running out of the mouth with- 
out any apparent effort. She took the breast well but con- 
tinued to vomit everything taken. There having been no 
movement of the bowels, she was given a high enema of a pint 
of water early in the morning of Aug. 23. Two sticks of 
smooth, dry, gray feces the size of the finger were obtained. 
Two doses of castor oil, given that afternoon, were vomited. 
The temperature remained normal and the abdomen lax 
until the morning of Aug. 24, although the bowels did not 
move and the vomiting continued. Distension of the 
abdomen developed during the morning, however, the tem- 
perature rose steadily all day and her general condition grew 
progressively worse. Another dose of castor oil was vomited. 
A high enema brought away a small amount of grayish 
material of the same character as that obtained from the first 
enema. She was seen in consultation at 5 p.m., Aug. 24. 

Physical Examination. She had evidently lost much 
weight. The face was drawn. There was no jaundice. She 
was quiet unless disturbed, but every few minutes regurgi- 
tated a small amount of yellowish-brown, watery material. 
The fontanelles were depressed. There was no rigidity of the 
neck and no neck sign. The pupils were equal and reacted to 
light. The mouth and throat were not examined. The 
heart and lungs were normal. The liver and spleen were 
not palpable. The abdomen was much enlarged and so tense 
that nothing could be determined by palpation. It was 
everywhere tympanitic, but apparently not tender. The 
superficial veins were distended. The extremities were 
normal. There was no spasm or paralysis. The knee-jerks 
were equal and normal. Kernig's sign was absent. The 
diapers were wet, but not stained by bile. The rectal tem- 
perature was 102.8° F. ; the pulse, 172. 



DISEASES OF THE NEW-BORN. 69 

Diagnosis. The absence of any physical signs of increased 
cerebral pressure or meningeal irritation excludes all forms 
of cerebral disease as the cause of the vomiting and obstipa- 
tion. Disease of the brain would not, moreover, account for 
the gray color of the feces. The distension and rise of tem- 
perature are undoubtedly due to some complication of the 
original condition, the symptoms of which are vomiting and 
obstipation. The early onset and the persistence of the vom- 
iting, taken in connection with the absence of meconium, the 
small amount of intestinal contents obtained by enemata 
and the absence of all signs of inflammation in the abdomen 
and of fever until this morning show conclusively that there 
is some congenital obstruction of the digestive tract. The 
amount of the vomitus, the character of the vomiting, the 
presence of bile in the vomitus, the absence of bile in the in- 
testinal contents and the absence of jaundice and bile in the 
urine prove that the obstruction is situated below the en- 
trance of the common bile duct into the duodenum. The 
fact that a soft rubber catheter could be passed well into 
the intestine and that a pint of water could be injected at 
one time shows that the obstruction must be located above 
the large intestine. It is impossible, however, to determine 
in what part of the small intestine below the duodenum the 
obstruction is located. It is probable, however, judging 
from the small amount of intestinal contents obtained, that 
it is situated in the lower portion of the ileum. While it is 
possible that the obstruction may be due to constriction by 
a band or peritoneal adhesions, the chances are very much in 
favor of a Congenital Malformation of the Intestine. 

The distension and fever are almost certainly the result of 
a complicating peritonitis as the result of infection. 

Prognosis. The outlook is practically hopeless. There 
is a small chance of finding some condition, like obstruction 
from a band or adhesions, which can be relieved. Even so, 
however, the complicating peritonitis will probably prove 
fatal. In all probability, however, the obstruction is due to 
some irremediable malformation of the intestine. 

Treatment. There is no possible hope of recovery without 
an operation. An exploratory laparotomy should, therefore, 
be done at once. 



70 CASE HISTORIES IN PEDIATRICS. 

CASE 4. Martha R., the third child of healthy parents, 
was born at full term after a normal labor and was apparently 
normal at birth. She was seen when three and a half months 
old. She was breast-fed entirely for two weeks, given one 
part of whole milk and two parts of water In addition for two 
months, then milk and water alone. Her weight at birth 
was not known, but she had evidently gained a little. The 
movements had been whitish in color from the first. Jaundice 
was first noticed when she was ten or twelve days old and 
had persisted, with a certain amount of increase, ever since. 
It was thought that the urine was light-colored in the begin- 
ning, but that it very soon became greenish and had so 
continued. The abdomen was large at birth and had so 
remained. The baby had seemed fairly well on the whole, 
but had vomited occasionally and had had two loose white 
movements daily. It was thought that she had had a little 
fever from time to time. 

Physical Examination. She was fairly developed and nour- 
ished. There was marked jaundice of the skin, mucous 
membranes and conjunctivae. The anterior fontanelle was 
4 cm. in diameter and level. She was perfectly intelligent. 
The mouth and throat were normal, and there were no snuf- 
fles. There was no rosary. The heart and lungs were normal. 
The upper border of the liver flatness was at the upper border 
of the fifth rib in the nipple line. The lower border of the 
liver was palpable, running from the right anterior superior 
spine to the left costal border in the nipple line. The notch 
was indistinctly palpable in the median line; the edge was a 
little rounded, the surface smooth. The gall bladder was not 
felt. The spleen was palpable, running out from beneath 
the costal border in the anterior axillary line, downward to 
the level of the navel, and backward and upward under the 
ribs in the posterior axillary line. It extended 4 cm. below 
the costal border and was 6 cm. wide. There was a moderate- 
sized umbilical hernia. There were no signs of fluid in the 
abdomen and no other masses were felt. The abdomen was 
not distended, except by the enlarged liver and spleen. 
Rectal examination was negative. The cervical lymph nodes 
were slightly enlarged; the axillary and inguinal were not. 



DISEASES OF THE NEW-BORN. 7 1 

There was a slight intertrigo about the buttocks and genitals, 
but no lesions of scratching. There were no mucous patches 
and no scars of any old eruption. The extremities were 
normal. The weight was nine pounds. 

The urine was greenish in color, of a specific gravity of 
1,009, ^^d ^cid in reaction. It contained no albumin but 
considerable bile. 

The stools were somewhat loose, grayish-white in color, 
foul in odor. Examination by the corrosive sublimate test 
showed a total absence of bile. 

Diagnosis. The history, physical examination, urine and 
stools together present such a characteristic picture of 
Congenital Obliteration of the Bile Ducts that a 
differential diagnosis is hardly necessary. The only other 
things to be considered as possibilities are congenital syphi- 
lis and indigestion with obstruction of the common or 
hepatic duct. Enlargement of the liver and spleen, some- 
times accompanied by jaundice, do occur in congenital 
syphilis. The absence of bile in the stools and of other 
signs of syphilis, such as snufiles, mucous patches and the 
scars of old eruptions, exclude it in this instance. Indiges- 
tion with obstruction of the bile ducts is extremely unusual 
at this age, the liver but little enlarged, the spleen not at all. 
It can, therefore, also be ruled out. An important point to 
be remembered in this connection is the fact that there is a 
colorless form of bile, leucohydrobilirubin. It is never safe, 
therefore, to conclude absolutely, without a chemical test, 
that a stool does not contain bile, even if it is white or clay- 
colored. 

Prognosis. The prognosis is absolutely hopeless. Cases 
almost never live to be more than eight months old. Death 
occurs from debility, secondary hemorrhage or intercurrent 
disease. 

Treatment. There is no curative treatment. The patients 
probably live longer and certainly digest better and are more 
comfortable, however, if fat is eliminated from their food. 



72 



CASE HISTORIES IN PEDIATRICS. 



CASE 5. Robert R., the first child of healthy parents, had 
always been very well. He had been entirely breast-fed, had 
never had a cough and had not cried more than a normal baby 
should. When he was about three months old his mother 
noticed a bunch in the right groin. She had not seen it 
before, but could not say whether it had been there before or 
not. She thought that it had increased a little in size since 
she first discovered it. It apparently caused the baby no 
discomfort. He was seen in consultation a week after the 
discovery of the tumor. 

Physical Examination. He was in splendid general con- 
dition, large, fat and of good color. The fontanelle was level. 
There was no rosary. The heart, lungs and abdomen were 
normal. The liver was palpable 2 cm. below the costal border 
in the nipple line ; the spleen was not palpable. The extremi- 
ties were normal. There was no spasm or paralysis; the 
knee-jerks were equal and normal; there was no Kernig's 
sign. There was no enlargement of the peripheral lymph 
nodes. 

There was a slightly elastic swelling, about the size and 
shape of a catbird's egg, in the right inguinal region just 
above the entrance to the scrotum. It was not tender, hot 
or red. It could be pushed upward and downward en masse, 
but could not be pushed into either the abdomen or the scro- 
tum. It did not gurgle. The inguinal rings felt alike on both 
sides, and nothing could be felt in them. Both testicles were 
in the scrotum. 

Diagnosis. The history is unimportant in this instance. 
Babies often develop an inguinal hernia without cough or 
excessive crying and the mother does not know whether the 
swelling was present at birth or appeared later. The diag- 
nosis must be made entirely on the physical examination. 
A partially descended testicle can be ruled out because both 
testicles are in the scrotum. The elasticity rules out a 
hyperplastic lymph node. It is, moreover, very unusual to 
find only one enlarged lymph node in the groin, and a large 
lymph node is seldom so movable. The normal condition of 
the inguinal ring rules out hernia. The absence of gurgling 
and the irreducibility of the mass are corroborative evidence 



DISEASES OF THE NEW-BORN. 73 

against hernia. The shape, elasticity, mobility and irreduci- 
bility are characteristic of an Encysted Hydrocele of the 
Cord, which is the diagnosis. 

Prognosis. There is, of course, nothing dangerous about 
this condition. A single tapping usually cures it. 

Treatment. The treatment is aspiration with a fine needle. 
One tapping will probably cure it. If it does not, the tapping 
may be repeated. i\n operation will almost certainly not be 
necessary. 



74 



CASE HISTORIES IN PEDIATRICS. 



CASE 6. Harriott H., the first child of healthy parents, 
was born at full-term after a difficult forceps delivery, and 
weighed eight pounds. She breathed at once and seemed 
normal in every way except that her head was much swollen 
and out of shape. The general swelling went down in twenty- 
four hours and then a circumscribed swelling was noticed on 
the right side of the head. This had diminished a little in 
size and had apparently caused her no discomfort. She had 
seemed normal in every way except for the swelling on the 
head. She was seen in consultation when a week old. 

Physical Examination. She was well developed and nour- 
ished and of good color. There was a swelling, the size of a 
duck's egg, over the right parietal bone. This swelling was 
soft and fluctuating, but neither red nor tender. Pressure on 
it caused no bulging of the anterior fontanelle and no dis- 
comfort or signs of increased cerebral pressure. It did not 
extend beyond the borders of the right parietal bone. The 
pupils were equal and reacted to light. There was no rigidity 
of the neck. The anterior fontanelle was level. The heart, 
lungs and abdomen were normal. The liver was palpable 
2 cm. below the costal border in the nipple line; the spleen 
was not palpable. The extremities were normal; there was 
no spasm or paralysis; the knee-jerks were equal and normal; 
there was no Kernig's sign. 

Diagnosis. This tumor corresponds in every way to a 
Cephalhematoma and undoubtedly is one. The caput 
succedaneum is hard, does not fluctuate and is not limited to 
a single bone. It disappears in from twenty-four to forty- 
eight hours. The swelling first noticed in this instance was 
undoubtedly a caput. A meningocele protrudes through one 
of the normal openings in the skull, a fontanelle or suture, 
and is most often situated at the root of the nose or in the 
occipital region. Pressure on it causes bulging of the anterior 
fontanelle, discomfort and symptoms of increased cerebral 
pressure, such as spasm or twitching of the extremities. An 
abscess is hot, red and tender, and is accompanied by fever 
and symptoms of general constitutional disturbance. 

Prognosis. The prognosis is almost absolutely good if the 
tumor is let alone. It is practically certain that it will dis- 




Harriott H. Case 6. 




Multiple Cephalhematoma. 



DISEASES OF THE NEW-BORN. 75 

appear in from three to six weeks. It is only in the rarest 
instances that ossification of the elevated periosteum, with 
the formation of a permanent deformity as the result, occurs. 
If it is aspirated or opened it may become infected and an 
abscess result. 

Treatment. The treatment is to let it alone. External 
applications cannot hasten the absorption of the blood. 
Aspiration will hasten the disappearance of the tumor, but 
is unnecessary and carries with it the danger of infection. 
An incision is unnecessary, will leave a scar and is very likely 
to result in infection and the formation of an abscess. 



76 CASE HISTORIES IN PEDIATRICS. 

CASE 7. William P. was the second child of healthy par- 
ents. The position was O. D. P. He was delivered by high 
forceps and weighed eleven pounds. The physician in charge 
pulled very hard on one shoulder, probably the right, during 
the delivery, and thought that he felt something give way. 
The baby was somewhat white at birth, did not respond to 
artificial respiration, and mouth-to-mouth insufflation was 
necessary. He then cried and seemed perfectly normal 
except that it was noticed at once that there was some 
trouble with the face and the right arm. He did not close 
the right eye and there was no motion of the right side of 
the face. The right arm hung limp at the side and was used 
but little. There had been some improvement in the condi- 
tion of both face and arm. He was seen in consultation when 
one week old. He was not nursed, but took the bottle well 
and had no disturbance of digestion. 

Physical Examination. He w^as well -developed and nour- 
ished. His color was good. The fontanelle was 3 cm. in 
diameter and level. The head was of good shape. There 
was no rigidity of the neck. There was a hemorrhage into 
the right conjunctiva. The pupils were equal and reacted 
to light. The left eye could be closed entirely; the right 
only partially. The mouth was drawn to the left when he 
cried. There were forceps scars on the left forehead, but none 
on the right. The heart and lungs showed nothing abnormal. 
The level of the abdomen was that of the thorax. The cord 
was still on, but was healthy. The liver was palpable 3 cm. 
below the costal border in the nipple line ; the spleen was not 
palpable. The genitals were normal. The right arm hung 
limply by the side, extended at the elbow and wrist, and with 
the palm turned backward. He made no active motions 
with this arm except at the wrist and with the fingers. His 
grip was strong. Passive motions were not limited. The 
arm was not tender, and there were no evidences of fracture 
or dislocation. The left arm and the legs were normal and 
showed no signs of spasm or paralysis. The knee-jerks were 
equal and lively. There was no Kernig's sign. There was 
no enlargement of the peripheral lymph nodes. The rectal 
temperature was normal. 



DISEASES OF THE NEW-BORN. 77 

Diagnosis. The diagnosis of facial paralysis is evident. 
The inability to close the eye shows that the upper branch 
of the facial nerve is involved and that the paralysis is, there- 
fore, peripheral in origin. It was undoubtedly caused by the 
pressure of the forceps blade on the trunk of the nerve. 
The hemorrhage into the right conjunctiva is presumably 
also due to injury from the forceps blade. 

The fiaccidity of the right arm at once rules out cerebral 
paralysis, in which the paralysis is spastic. Moreover, in 
cerebral paralysis due to injury at birth, the paralysis is 
never limited to one extremity, and if an extremity is affected, 
it is always affected as a whole, not in part. If the baby was 
older, infantile paralysis (poliomyelitis) might be considered, 
but, as the paralysis was present at birth, this is an impossi- 
bility. It corresponds perfectly to the so-called "obstetric 
paralysis" of the upper-arm type, in which there is a paralysis 
of certain muscles from injury to the brachial plexus during 
labor. The stretching of the plexus caused by the pulling on 
the shoulder was presumably the cause in this instance. The 
characteristic position of the arm is due to the fact that only 
certain muscles are involved, namely, the deltoid, biceps, 
brachialis anticus, supinator longus, infraspinatus, supraspi- 
natus and serratus magnus. 

This baby, therefore, shows both the facial and arm types 
of Obstetric Paralysis. 

Prognosis. The prognosis of the facial paralysis is almost 
absolutely good. Recovery almost invariably takes place in 
a few weeks. 

The prognosis of the paralysis of the arm is not as good. 
There will certainly be a great deal of improvement, but 
equally certainly some permanent disability. How great 
this disability will be cannot be told for a year or two, after 
which time little improvement can be expected. 

Treatment. The facial paralysis requires no treatment. 
The only treatment indicated for the arm at present is a 
sling to take the weight of the arm off the shoulder muscles. 
Massage and electricity may be begun in about three weeks. 
The object of them both is to keep up the tone of the muscles 
until the nerves regain their power. Faradism should be 



78 CASE HISTORIES IN PEDIATRICS. 

used, if the muscles react; if they do not, galvanism. Mus- 
cle training by proper exercises is the best form of treatment 
and shoidd be begun when the baby is a few months old. 

If, at the end of a year, there has been but little improve- 
ment, operation on the nerve trunks will be worthy of con- 
sideration. The results of this operation have been, in a 
number of instances, very satisfactory. It is, however, a 
delicate operation and should be performed only by those 
accustomed to the surgery of the nerves. 



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Obstetric Paralysis. — Facial type. Case 7. 




Obstetric Paralysis. — Arm type. Case 7. 



DISEASES OF THE NEW-BORN. 79 

CASE 8. Marion S, was the first child of healthy parents. 
There had been no miscarriages. She was born at full term, 
after a moderately hard forceps delivery, and weighed seven 
pounds. Nothing abnormal was noticed about her at birth. 
She was not nursed, but was at once given modified cows' 
milk, on which she had done very well. A lump was noticed 
in her neck when she was four and one-half weeks old. Both 
her mother and the nurse were positive that there had been 
no lump there before. There had been no evidence of pain 
or tenderness in the neck and the swelling apparently caused 
her no inconvenience. She was seen when five weeks old. 

Physical Examination. She was well developed and 
nourished and of good color. The posterior fontanelle was 
closed; the anterior, three cm. in diameter and level. She 
held her head straight and moved it freely in all directions 
without pain. There was a hard, non- tender bunch, the size 
of an almond, in the lower third of the sternal portion of the 
right sternocleidomastoid muscle, and the lower third of the 
clavicular portion was thickened and hard, but not tender. 
The swellings were not red or hot. The skin and subcutane- 
ous tissues were freely moveable over them. The mouth and 
throat were normal. The heart, lungs, abdomen and ex- 
tremities were normal, as were the deep reflexes. The liver 
was palpable two cm. below the costal border in the nipple 
line. The spleen was not palpable. There was no enlarge- 
ment of the peripheral lymph nodes. There was no nasal 
discharge and no eruption on the skin. The rectal tempera- 
ture was normal. 

Diagnosis. The tumor and thickening are distinctly within 
the sheath of the sternocleidomastoid muscle. They cannot, 
therefore, be due to enlarged cervical lymph nodes or con- 
nected with the thyroid gland, as was supposed by the former 
attendant. Tumors and thickening of the sternocleidomas- 
toid muscle in early infancy are almost invariably the result 
of a hemorrhage into the muscle during labor. Other causes, 
such as syphilis and malignant disease, are so extremely 
unusual that it is not necessary to consider them. The 
physician in charge did not notice anything abnormal at 
birth, however, and the mother and nurse affirm that the 



80 CASE HISTORIES IN PEDIATRICS. 

tumor did not appear until the baby was more than four weeks 
old. These statements do not appear consistent with the 
diagnosis of hematoma of the sternocleidomastoid muscle, a 
condition which develops at birth. It is easy to explain them, 
however, when it is remembered that the effusion is at first 
liquid and very easily overlooked unless there is tenderness. 
The tumor is usually overlooked, therefore, until it becomes 
hard from the organization of the clot and the formation of 
scar tissue, unless the unusual position of the head, which is 
turned a little downward and toward the affected side, calls 
attention to it. In this instance the mother and nurse were 
probably also poor observers. The statements as to the late 
appearance of the tumor do not, therefore, invalidate in any 
way the diagnosis of Hematoma of the Sternocleido- 
mastoid Muscle. 

Prognosis. The lesions in this instance are relatively slight 
and there is no deformity or limitation of motion. It is 
practically certain, therefore, that resolution will gradually 
take place and that there will not be sufficient retraction of 
the newly-formed tissue to cause torticollis. It will probably 
be a year before the swelling will entirely disappear. 

Treatment. Passive motion of the head to prevent con- 
tracture of the muscle should be made regularly. Massage 
of the thickened areas will probably hasten resolution. 



DISEASES OF THE NEW-BORN. 3l 

CASE 9. Catherine E. was delivered at full-term by low 
forceps after a long labor, and weighed nine pounds. Her 
mother had been married twice. Her only pregnancy by 
her first husband had resulted in a miscarriage at two or 
three months, after an accident. She thought that he had 
not had syphilis and had had no symptoms of it herself. 
Her second husband denied having had syphilis. The 
patient was the first child by the second husband. She is 
said to have cried vigorously immediately after birth. The 
nurse noticed, a few hours later, however, that she did not 
breathe naturally. The trouble with the breathing continued. 
When quiet, she breathed quickly and her color was fair. 
If disturbed, or if she made any exertion, she usually became 
very cyanotic. Sometimes she at first became very pale and 
then cyanotic. She seldom cried. The respiration was never 
noisy. She usually kept her mouth shut and was able to 
suck. She had apparently never had any fever and had never 
had any disturbance of the digestion. She was seen in con- 
sultation when about five weeks old. 

Physical Examination. She was fairly developed and nour- 
ished. When quiet, she breathed quickly but quietly. The 
alae nasi did not move, she kept her mouth shut and her 
color was good. There was, however, moderate retraction of 
the epigastrium and of the sides of the chest. When dis- 
turbed, the respiration became more rapid and labored, but 
not noisy. She kept her mouth open and was evidently 
distressed. She tried to cry but was unable to make much 
noise. She became very cyanotic, and the retraction of the 
epigastrium and sides of the chest was much increased. A 
probe was easily passed through both nostrils. There were 
no snuffles. The throat was normal both to inspection and 
palpation and no adenoids were felt with the finger. There 
was no increase of the thymus dullness, and the thymus 
could not be felt in the suprasternal notch. The cardiac 
impulse was indistinctly palpable in the fourth left space 
si cm. to the left of the median line. The right border of 
dullness was 2 cm. to the right of the median line. The action 
was regular; the rate varied between 140 and 180 according 
to the difficulty in breathing. The sounds were normal in 



82 CASE HISTORIES IN PEDIATRICS. 

character and there were no murmurs. There was marked 
dullness and diminished broncho-vesicular (much nearer 
vesicular than bronchial) respiration, with an occasional 
medium moist rale in the left front down to the cardiac area 
and in the upper left axilla, and over the whole right back 
except at the apex. There was hyperresonance and exagger- 
ated vesicular respiration over the rest of the lungs, and 
numerous fine moist rales were heard. The abdomen was 
normal. The liver was palpable 2 cm. below the costal border 
in the nipple line; the spleen was not palpable. The ex- 
tremities were normal. There was no spasm or paralysis. 
The knee-jerks were equal and normal. There was no en- 
largement of the peripheral lymph nodes. There was no 
eruption and no scars of any old eruption. There were no 
mucous patches about the anus. The rectal temperature 
was normal. 

Diagnosis. The problem is to find the cause of the diffi- 
culty in respiration and cyanosis. This cause is the diagnosis. 
The physical examination rules out obstruction in the nose, 
nasopharynx, pharynx and larynx, as well as pressure from 
an enlarged thymus. The heart shows nothing abnormal. 
Sometimes, however, the examination of the heart shows 
nothing abnormal in congenital heart disease even when 
there are marked symptoms. The signs in the lungs are so 
definite in this instance, however, that it is not necessary to 
take refuge in this explanation. The signs in the lungs show 
partial solidification. The possible explanations of this 
solidification are resolving pneumonia, syphilis of the lung 
and congenital atelectasis. 

Resolving pneumonia is mentioned merely because this 
was the diagnosis of another consultant. It can at once be 
ruled out because there was never any fever and the symptoms 
appeared within a few hours after birth. Syphilitic involve- 
ment of the lung sufficient to give such marked physical 
signs is very unusual and is found only in the severest cases 
in which there are many other signs of the disease. The 
negative family history and the lack of any other signs of 
syphilis rule it out in this instance. The early appearance 
and the persistence of the symptoms without fever are most 



DISEASES OF THE NEW-BORN. 83 

characteristic of atelectasis. The only point against it is 
that the baby is said to have cried vigorously at birth. This 
may have been an error of observation, but, if true, does not 
rule out atelectasis, because it is perfectly possible for a 
baby to cry loudly and yet not completely expand the lungs. 
The diagnosis is, therefore, Congenital Atelectasis. The 
fine moist rales heard over the rest of the lungs are undoubt- 
edly due to edema. 

Prognosis. The prognosis is very grave. There is very 
little chance of expansion of the atelectatic areas after five 
weeks, and the child cannot live long in its present condition. 

Treatment. There is no direct treatment for the atelecta- 
sis. The best that can be done is to feed the baby carefully, 
give it plenty of fresh air, administer oxygen when there is 
cyanosis, and stimulate it, if necessary. 



84 CASE HISTORIES IN PEDIATRICS. 

CASE 10. Roger S. was seen in consultation when three 
months old. He was the fifth child and was born at full 
term after a normal vertex labor. He was perfectly normal 
at birth, but when he was two days old it was noticed that 
he had some difficulty in breathing. This difficulty gradually 
increased for about three weeks, since when it had remained 
about the same. Inspiration was always noisy, whether he 
was awake or asleep. It was noisier when he was excited and 
when he was lying down, especially if he lay on his face. 
Expiration was quiet. He never became blue and never 
held his breath. His cry was always clear and he almost 
never coughed. He had at times a little difficulty in taking 
food. He was partly breast- and partly bottle-fed. His 
digestion had always been perfect and he had gained steadily 
in weight. 

Physical Examination. He was well developed and nour- 
ished, but a little flabby. He was somewhat pale, but not 
at all cyanotic. Inspiration was always accompanied by a 
crowing sound, which was more marked when he was fright- 
ened or excited. This noise was louder when he was lying 
down than when he was sitting up. He seemed uncomfortable 
when lying on his face. Expiration was perfectly quiet. 
His mouth was usually open, but the crowing sound was no 
louder and respiration was no more difficult when it was 
closed. His cry was perfectly clear. There was slight 
retraction of the epigastrium with almost every inspiration. 
This was more m^arked and was accompanied by marked 
retraction of the suprasternal and supraclavicular spaces 
when the crowing was louder. He was not at all cyanotic 
even when the crowing sound was the loudest. The anterior 
fontanelle was 4 cm. in diameter and level. The shape of the 
head was good. There was no craniotabes. The fauces, 
pharynx and nasopharynx showed nothing abnormal on 
either inspection or palpation. The thymic dullness was not 
increased and the thymus could not be felt in the suprasternal 
notch. The heart and lungs were normal. The chest was 
slightly flattened on the sides and the sternum was a little 
prominent. There was a moderate rosary. The abdomen 
was rather large, but otherwise normal. The lower border of 



DISEASES OF THE NEW-BORN. ;85 

the liver was palpable 2 cm. below the costal border in the 
nipple line; the spleen was not palpable. The extremities 
showed nothing abnormal. There was no spasm or paralysis. 
The knee-jerks were equal, but not very lively. Kernig's 
sign was absent. There was no enlargement of the peripheral 
lymph nodes. Trousseau's sign and the facial phenomenon 
were absent. 

Diagnosis. Laryngismus stridulus can be excluded at 
once because the crowing sound is continuous. Other less 
important points against laryngismus stridulus are the early 
onset and the absence of other signs of increased nervous 
irritability (Trousseau's sign, facial phenomenon, exaggerated 
reflexes) . Obstruction in the nose, nasopharynx and pharynx 
is excluded by the physical examination. Obstruction from 
pressure on the trachea by enlarged bronchial glands, new 
growths in the mediastinum or an enlarged thymus is ex- 
cluded by the fact that the interference is entirely with in- 
spiration. The sound resulting from obstruction in this 
locality is, moreover, not crowing in character. It cannot be 
due to obstruction within the larynx from inflammation or 
new growths, because the cry is clear and there is no cough. 
The obstruction must be, therefore, at the entrance of the 
larynx. The anatomical malformation which can produce 
this obstruction is a narrowing of the epiglottis with laxness 
of the ary-epiglottidean folds. This condition was found by 
laryngoscopic examination in this patient. The result of this 
condition, noisy inspiration, is known as Congenital 
Laryngeal Stridor. 

Prognosis. The prognosis is good, both as to life and 
recovery. The deformity disappears with the growth of the 
parts and the crowing gradually diminishes and finally ceases 
toward the end of the second year. 

Treatment. Nothing can be done to hasten the growth of 
the parts. It is important, however, to avoid, as far as 
possible, catarrhal processes in the respiratory tract. 



86 CASE HISTORIES IN PEDIATRICS. 

CASE II. Marjorie D. was seen in consultation when four 
days old. She was the second child of healthy parents, was 
born at full term after a normal, rapid labor, and weighed 
seven and one-quarter pounds. The older child was well 
and there had been no miscarriages. She seemed normal at 
birth, except that there was much mucus in the nose and 
throat, which was removed with considerable difficulty. 
There continued to be a profuse discharge of mucus, which 
at times accurr^ulated and caused severe suffocative attacks, 
relieved only by the mechanical clearing of the nose and 
throat. There was a constant rattling in the nose and throat 
between these attacks. Her cry was somewhat feeble and 
a little hoarse. Her mother's milk had appeared on the 
third day and seemed sufficient in quantity. She took the 
breast well, but was liable to have an attack of suffocation 
come on while nursing. At times she vomited during or im- 
mediately after nursing; at others, she retained several 
successive feedings without vomiting. The stools were 
still composed entirely of meconium. She passed urine, 
but infrequently and in small amounts. The rectal 
temperature had been normal. She had lost one pound in 
weight. 

Physical Examination. She was fairly developed and 
nourished. She was slightly jaundiced, but there was no 
cyanosis. There was no bulging of the fontanelles. She 
was sleeping quietly, but with a little rattling in the nose. 
Closing the mouth did not interfere with breathing or wake 
her up. A probe was easily passed through both nostrils. 
When the tongue was depressed a large amount of yellowish- 
white liquid, mixed with mucus, came up in the throat. 
When this was cleaned out and the operation repeated more 
of the same material appeared. Palpation of the throat 
showed nothing abnormal. Her cry was a little hoarse, but 
strong. There was no retraction anywhere. The heart, 
lungs and abdomen were normal. The stump of the cord 
was healthy. The lower border of the liver was palpable two 
cm. below the costal border in the nipple line. The spleen 
was not palpable. The extremities were normal. There 
was no spasm or paralysis. The knee-jerks were equal and 



DISEASES OF THE NEW-BORN. 87 

normal. Kernig's sign was absent. She took the breast 
well, swallowed without difficulty, nursed about five minutes 
and did not vomit. 

Diagnosis. The suffocative attacks are undoubtedly due 
to the collection of mucus in the nasopharynx. Why does 
this mucus collect and why was it present in such large 
quantities at birth? Is it because there is an excessive 
secretion as the result of some local irritation or is it because 
the secretion is not swallowed? A strong point against the 
existence of an excessive secretion from local irritation is the 
fact that the mucus was present in large amounts at birth. 
On the other hand, the child swallows milk, and, if it swallows 
milk, ought to be able to swallow mucus also. The material 
which comes up in the throat when the tongue is depressed 
looks like colostrum or thin pus, mixed with mucus. It is 
hard to believe it pus, when it is taken into consideration that 
the baby is only four days old, shows no evidences of infection 
and has always had a normal temperature and that there are 
no signs of an abscess from which the pus can come. It 
hardly seems possible, on the other hand, that it can be colos- 
trum, because she nurses and swallows well, and, according 
to the history, has at times taken several successive feedings 
without vomiting. It is possible, however, that she may not 
have taken as much at these feedings as was supposed, that 
although she swallows well she gets but little and that this 
little does not reach the stomach but accumulates in the 
esophagus. The persistence of the meconium-like stools 
also points to some obstruction to the entrance of milk into 
the gastrointestinal canal. A reasonable explanation of the 
symptoms is, therefore, that there is a malformation of the 
esophagus which does not interfere with swallowing but 
prevents the passage of mucus and milk into the stomach, 
that the suffocative attacks are due to the accumulation of 
mucus in the pharynx, that not as much milk is taken as was 
supposed, that several small feedings accumulate in the upper 
esophagus, that the accumulated material is forced up when 
the tongue is depressed and vomited when the reserv^oir is 
overfilled. It is easy to prove whether this explanation is 
correct or not by examining the material which comes up in 



88 CASE HISTORIES IN PEDIATRICS. 

the throat, and, if it proves to be milk, by passing a soft 
rubber catheter into the esophagus. 

The material from the throat contains many colostrum 
corpuscles, much mucus and no more leucocytes than are 
normally found in the colostrum. The catheter is easily 
introduced into the esophagus but meets an obstruction about 
four inches from the gums and can be passed no further. 
There is no doubt, therefore, that the symptoms are due to a 
Congenital Malformation of the Esophagus. This 
malformation is situated at about the junction of the upper 
and middle thirds, and is, judging from the usual condition 
in these cases, presumably an obliteration of the esophagus 
at this point. There is, for the same reason, probably an 
opening between the trachea and the lower portion of the 
esophagus. 

Prognosis. The prognosis is absolutely hopeless. The 
baby will die of starvation in a few days no matter what 
method of treatment is pursued. 

Treatment. The condition is irremediable. Surgical in- 
tervention is impossible. Life may be prolonged a little by 
rectal feeding and the subcutaneous injection of salt solution, 
but these measures can only postpone the fatal outcome a few 
days or possibly a week. 



DISEASES OF THE NEW-BORN. 89 

CASE 12. Eleanor S. was the fourth child of healthy 
parents. She was born at full term, after a normal labor, was 
normal at birth and weighed eight pounds. She was entirely 
breast-fed and had done well in every way, except that she 
had rather too many movements. Enlargement of the 
breasts began when she was four or five days old and increased, 
so that when she was ten days old they were much enlarged. 
There having been no diminution in the size of the breasts, 
she was brought on that account when three weeks old. 

Physical Examination. She was well developed and nour- 
ished and of good color. The posterior fontanelle was still 
open; the anterior fontanelle was level. The mouth was 
healthy. The heart, lungs and abdomen showed nothing 
abnormal. The navel was normal. The lower border of the 
liver was palpable one cm. below the costal border in the 
nipple line. The spleen was not palpable. The extremities 
were normal. There was no spasm, paralysis or disturbance 
of the deep reflexes. There was no enlargement of the pe- 
ripheral lymph nodes. Both breasts were markedly swollen, 
the area at the base being about that of a fifty-cent piece and 
the shape that of the engorged breast in the adult. They 
were not red, hot or tender. A milky fluid could be easily 
expressed from them. The rectal temperature was 99° F. 

Diagnosis, The normal temperature and the absence of 
heat, redness and tenderness prove that there is no inflamma- 
tion of the breasts. The condition ought not, therefore, to 
be called ''mastitis," as it usually is. It is simply a Physio- 
logical Engorgement of the Breasts, presumably due to 
the passage into the fetus of some of the hormones circulating 
in the blood of the mother. These stimulate the production 
of milk in the child as well as in the mother. 

Prognosis. The secretion of milk will gradually cease and 
the enlargement of the breasts subside. There is no danger 
of the development of mastitis if the breasts are let alone. 
If they are handled or squeezed, they may become inflamed. 

Treatment. The treatment is to let the breasts entirely 
alone. 



90 CASE HISTORIES IN PEDIATRICS. 

CASE 13. Sidney K. was the first child of healthy parents. 
There was no history of syphilis and there had been no mis- 
carriages. He was born May 28, about a week premature. 
He weighed six pounds and was put at once on a weak 
modified milk. Jaundice developed on the second day and 
became very marked. He took his food well and had not 
vomited. The movements consisted at first of meconium; 
later the bowels were very constipated, but the movements 
were yellow and smooth. The temperature was normal or 
slightly subnormal. The urine had not stained the diapers. 
He was seen in consultation June 5, when eight days old. 

Physical Examination. He was small and somewhat emaci- 
ated, having lost a pound. There was deep jaundice of the 
skin and conjunctivae. He did not seem especially feeble. 
The fontanelle was level. The mouth and throat were nor- 
mal. The heart, lungs and abdomen were normal. The 
umbilicus was healed. The liver was palpable 2 cm. below 
the costal border in the nipple line. The spleen was not 
palpable. The extremities were normal; there was no 
spasm or paralysis; the knee-jerks were equal and normal. 
The genitals were normal. There were no ulcerations about 
the anus. There was no eruption or enlargement of the periph- 
eral lymph nodes. The rectal temperature was normal. 

The urine was not examined, but the diapers were not 
stained by it. 

The movements were small, constipated, brownish-yellow 
and well-digested. 

Diagnosis. When jaundice develops during the first few 
days of life it is always a temptation to call it icterus neona- 
torum and to dismiss it without further consideration. There 
are other causes of jaundice at this age, however, and while a 
snap diagnosis of icterus neonatorum will be correct in the 
vast majority of cases, it will occasionally be wrong, and 
wrong often enough to justify a careful differential diagnosis 
in every instance. The diseases to be considered are, septic 
infection of the newborn, congenital obstruction or oblitera- 
tion of the bile ducts, acute infectious jaundice, congenital 
syphilis and congenital icterus. 

The early appearance of the jaundice, the presence of deep 



DISEASES OF THE NEW-BORN. 9I 

jaundice without cyanosis, the good general condition and 
the absence of fever and of enlargement of the liver and spleen 
rule out septic infection of the newborn. The absence of 
enlargement of the liver and spleen and of bile in the urine, 
together with the presence of bile in the stools, rule out 
congenital obliteration of the bile ducts. Acute infectious 
jaundice is very uncommon at this age. It is excluded by 
the absence of bile in the urine and the presence of bile in the 
stools. Congenital syphilis is suggested by the prematurity. 
There are, however, other causes for prematurity than syphi> 
lis. The good family history and the absence of miscarriages 
are against it. The normal size of the liver and spleen, 
together with the absence of all signs of syphilis, rule it out. 
Congenital icterus is an extremely rare condition and is 
excluded because the jaundice was not present at birth and 
the spleen is not enlarged. The diagnosis by exclusion is, 
therefore. Icterus Neonatorum. The development of the 
jaundice on the second day, the good general condition, 
the presence of bile in the stools, its absence in the urine, 
the normal temperature and the absence of enlargement of 
the liver and spleen are all consistent with this diagnosis. 

Prognosis. Icterus neonatorum does not affect the general 
condition. The jaundice will probably not increase in in- 
tensity, but will not disappear entirely for several weeks. 

Treatment. No treatment is indicated. Icterus neona- 
torum is a physiological condition and is due to the mere 
mechanical difficulty which the bile encounters in passing 
through the bile capillaries. There is, therefore, no object 
in giving cathartics. Cleaning out the intestine cannot 
affect the conditions in the bile capillaries. It has been shown 
that calomel, like the otheir so-called " cholagogues," does 
not increase the flow of bile. If it did, it would be contra- 
indicated rather than indicated in this condition. There is 
no indication for changing the food, because sufficient bile 
to carry on digestion enters the intestine, only the excess 
passing into the circulation. 



92 CASE HISTORIES IN PEDIATRICS. 

CASE 14. Robert M. was the third child of healthy 
parents. The other children were well and there had been 
no miscarriages. He was born at full term, after a normal 
labor, and appeared normal at birth. He was given at first 
a weak mixture of condensed milk and water. This did not 
agree with him and he was then given barley water for a few 
days, and after that a number of proprietary foods in rapid 
succession, all of them being prepared with water. He had 
vomited a great deal from the first and the stools, although not 
increased in number above the normal, had always been green 
and usually undigested. He had lost weight steadily. He had 
several convulsions October 9. Two days later he suddenly 
became very feeble and since that time had taken almost no 
nourishment. He was admitted to the Children's Hospital, 
October 14, when six weeks old. 

Physical Examination. He was poorly developed and 
emaciated. The skin was pale, with slight cyanosis of the 
lips and nails. The surface of the body was cold. He was 
extremely feeble, was unable to cry aloud and seldom opened 
his eyes. The anterior fontanelle was two cm. in diameter 
and depressed; the posterior was closed. The bones of the 
skull overlapped. The mouth and pharynx were dry. The 
respiration was very shallow. The cardiac impulse was 
neither visible nor palpable. The cardiac area was normal. 
The action was irregular and the sounds feeble. There were 
no murmurs. The lungs showed nothing abnormal. The 
abdomen was full and tympanitic, but otherwise normal. 
The liver and spleen were not palpable. The genitals were 
normal. Both cheeks were somewhat indurated. There was 
marked induration of the whole of the back and of both upper 
and lower extremities, except that the palms and soles were 
not involved. There was no pitting on pressure. The color 
of the indurated areas was slightly yellowish. He was 
so rigid that when he was lifted from the bed by a hand 
placed under his back there was no change in his position. 
He did not move his extremities, but a certain amount 
of passive motion could be elicited with some difficulty. 
The character of the knee-jerk could not be determined, 
because of the rigidity. The rectal temperature was 



DISEASES OF THE NEW-BORN. 93 

94.2° F., the pulse could not be obtained, the respiration 
was 50. 

Diagnosis. The diagnosis of Sclerema Neonatorum is so 
evident in this instance that it is hardly necessary to consider 
any other condition. The distribution of the induration, the 
color of the indurated areas, the absence of pitting on pres- 
sure and the sparing of the palms, soles and external genitals 
are all characteristic of this condition and distinguish it from 
edema, in which the color is pale, there is pitting on pressure 
and the palms, soles and genitals are involved. The low 
temperature is also characteristic of sclerema neonatorum. It 
is seldom much below normal in edema. 

Prognosis. The prognosis is practically hopeless. He 
will probably not live more than twenty-four hours. 

Treatment. He should be wrapped in cotton, placed in a 
padded crib or basket and surrounded by heaters or, better, 
electric heating pads. In fact, the same measures should be 
used to keep up his temperature as are employed in the case 
of premature infants (see Case i). The best food for him 
is human milk, diluted with an equal amount of water and 
given with a dropper or Breck feeder. He will probably not 
be able to take more than half an ounce every one and one- 
half hours. If human milk is not obtainable, a modification 
of cows' milk, containing i% of fat, 5% of milk sugar, 0.50% 
of whey proteids and 0.25% of casein, with lime water 25% of 
the milk and cream in the mixture, may be substituted. 
He should also be given ^-q of a grain of strychnia every 
three hours, supplemented, if necessary, by caffeine-sodium 
benzoate or salicylate in doses of one eighth of a grain. 



94 CASE HISTORIES IN PEDIATRICS. 

CASE 15. Ursula M., the first child of healthy parents, 
was born at full term, September 23, after a normal labor, 
and was normal at birth. She had been breast-fed and, ex- 
cept for considerable colic, had done well. The cord came 
off on the sixth day. The navel w^as healthy and continued 
dry until October 3. There had been since then, however, 
a thin, purulent discharge from the navel. She was seen 
October 6. 

Physical Examination. — She was small, but was developed 
and nourished, and of good color. The fontanelle was level. 
The mouth was healthy. The heart and lungs were normal. 
The liver was palpable tAvo cm. below the costal border in 
the nipple line. The spleen was not palpable. The abdo- 
men showed nothing abnormal, except at the navel. There 
was a tumor, the size of a small pea, at the bottom of the 
navel, which was normally sunken. This tumor looked like 
a mass of granulation tissue. There was a small amount of 
thin purulent discharge from it. Careful examination with 
a probe failed to disclose any canal in it. The extremities 
were normal. There were no mucous patches about the anus 
and there was no eruption on the skin. There was no en- 
largement of the peripheral lymph nodes. The rectal tem- 
perature was 99° F. 

Diagnosis. The absence of a central canal in the mass at 
the navel and the fact that the discharge is purulent, rather 
than thin and watery or fecal, shows that it cannot be a 
prolapse of Meckel's diverticulum. Patency of the urachus 
is almost never accompanied by the presence of a tumor. 
The absence of a central canal and of a discharge of urine 
from it shows that this mass cannot be connected with the 
urachus. The good family history and the absence of all 
other evidences of syphilis show that it cannot be syphilitic 
in nature. It is undoubtedly merely a mass of granulation 
tissue, which has formed as the result of the imperfect healing 
of the navel ; that is, it is a Granuloma of the Navel. 

Prognosis. If it is untreated, it is likely to persist for 
several weeks, or even months, and will very probably in- 
crease in size. It will disappear in a few days, however, if 
properly treated. 



DISEASES OF THE NEW-BORN. 95 

Treatment, It will undoubtedly dry up and disappear in 
one or two weeks, if it is kept dry and pow^dered with aristol. 
It will dry up much quicker, however, if it is touched daily 
with a stick of nitrate of silver. If it does not dry up in a 
few days under treatment with the nitrate of silver stick, a 
small ligature should be tied about its base, or it may be 
snipped off with the scissors and the base treated with nitrate 
of silver or the actual cautery. Ligation is, however, the 
simpler and therefore the preferable procedure. 



96 CASE HISTORIES IN PEDIATRICS. 

CASE 1 6. Catherine G. was born at full term after a 
normal labor. She was normal at birth, except for a pro- 
jecting red mass, about the size of the cord, at the navel. 
This mass was left after the cord came off and had not 
changed in size since then. It bled freely when irritated, 
and there was a dark-colored, foul-smelling discharge from 
it. She had been breast-fed, had had no disturbances of 
digestion, had gained steadily in weight and had seemed 
perfectly well except for the mass at the navel. She was 
admitted to the Infants' Hospital when a month old. 

Physical Examination. She was well developed and 
nourished and of good color. The posterior fontanelle was 
almost closed, the anterior was three cm. in diameter and 
level. The mouth and throat were normal. There was no 
rosary. The heart and lungs were normal. The level of the 
abdomen was a little above that of the thorax. It showed 
nothing abnormal except a tumor at the navel. This tumor 
protruded from the umbilical ring, was one inch long and 
one-half inch in diameter. Its surface was covered with 
mucous membrane, which was bleeding from many small 
points. The centre of its apex was occupied by a canal, also 
lined with mucous membrane, which admitted a probe two 
inches. There was a small amount of thin grayish-yellow 
discharge, with a slightly fecal odor, from the opening. 
There was no evidence of inflammation about the navel. 
The lower border of the liver was palpable two cm. below the 
costal border in the nipple line. The spleen was not palpable. 
The extremities were normal. There was no spasm or 
paralysis. The knee-jerks were equal and normal. Ker- 
nig's sign was absent. There was no enlargement of the 
peripheral lymph nodes. 

Diagnosis. This tumor is too large to be a granuloma. 
It is, moreover, covered with mucous membrane and has a 
central canal, conditions not consistent with a granuloma. 
The discharge from the central canal is certainly not urine. 
Patency and protrusion of the urachus can, therefore, be 
excluded. The characteristics of the discharge are those of 
the contents of the small intestine. The facts that the 
surface of the tumor is covered with mucous membrane, 



DISEASES OF THE NEW-BORN. 97 

that it has a central canal and that there is a discharge of 
material from it resembling the contents of the small intes- 
tine, justify the diagnosis of persistence, protrusion and 
eversion of the omphalomesenteric duct. This condition is, 
however, more often spoken of as Prolapse of Meckel's 
Diverticulum. 

Prognosis. This condition is not dangerous to life. It 
is, however, a source of annoyance and there is always the 
possibility of infection of the mucous surface. There is little 
probability of recovery without an operation. 

Treatment. The only rational treatment, when the pro- 
trusion is as marked as in this instance, is the removal of 
Meckel's diverticulum at its origin from the intestine and 
extirpation of the navel. 



98 CASE HISTORIES IN PEDIATRICS. 

CASE 17. John B. was the first child of healthy parents, 
except that his mother had always been anemic. There had 
been no miscarriages. His father denied syphilis and showed 
no signs of having had it. There had never been any " bleed- 
ers " in either family. He was delivered at 6 a.m., August 4, 
at full term, by low forceps, after a short labor, and weighed 
nine pounds. He was normal except for a slight abrasion on 
the right cheek and another on the back of the neck, and 
breathed at once. He was put to the breast that afternoon, 
took hold well, but got nothing. The next morning he was 
ordered one-half ounce of a mixture containing 1% of fat, 
5% of sugar, 0.25% of whey proteids and 0.25% of casein 
every two hours, but as this was vomited it was stopped 
after three feedings. Since then he had had only boiled 
water. Oozing of blood began about midnight, August 5, 
from both abrasions, and a hematoma, the size of half a 
walnut, appeared at the site of each of them. The oozing 
continued and he lost about half an ounce of blood during 
the night. The bleeding was then controlled by pads soaked 
in a 1-10,000 solution of adrenalin chloride. Several small 
hemorrhagic areas appeared in the roof of the mouth and one, 
the size of a dime, on the back that morning, August 6. 
He had not vomited blood or had any blood in his movements. 
The highest rectal temperature was 99® F. He had been given 
10 ccm. of fresh rabbit's serum at 3.30 P.M., August 6. He 
was seen in consultation at 5 p.m. 

Physical Examination. He was well developed and nour- 
ished, but moderately pale. The respiration was a little 
rapid. He seemed uncomfortable and was inclined to moan. 
The fontanelle was level. There was no rigidity of the neck. 
There were slight ecchymoses in the right eyelids. There 
were several ecchymotic areas, varying in size from that of a 
split pea to that of a twenty-five cent piece, on the upper 
part of the right cheek. There was an abrasion, about 2 cm. 
long and i cm. wide, over the largest ecchymosis, where there 
was also some swelling. It was scabbed over and not oozing. 
There was an ecchymotic area, the size of a twenty-five cent 
piece, on the back of the left neck, where there was also a 
scab, but no oozing. There was an ecchymotic area, the size 



DISEASES OF THE NEW-BORN. 99 

of a ten-cent piece, on the lower back, and half a dozen ecchy- 
motic areas, the size of a pinhead or a little larger, in the 
roof of the mouth. The heart and lungs were normal. The 
abdomen was negative. There was no bleeding from the 
stump of the cord. The liver was palpable 3 cm. below the 
costal border in the nipple line; the spleen was not palpable. 
The extremities were normal ; there was no spasm or paraly- 
sis; the knee-jerks were equal and normal; Kernig's sign was 
absent. There was no enlargement of the peripheral lymph 
nodes. There was no bleeding from the point where the 
rabbit's serum was injected. 

The movements which were seen were loose, dark-green 
and contained considerable mucus, but no blood. 

Diagnosis. The diseases to be considered here are congeni- 
tal syphilis, hemophilia and hemorrhagic disease of the new- 
born. Syphilis can be excluded on the negative family his- 
tory, the absence of miscarriages, the good general condition, 
the absence of all signs of syphilis, such as enlargement of 
the liver and spleen and eruptions, and the fact that hemor- 
rhage occurs only in the severest cases which show many 
other signs of the disease. Hemophilia can be excluded on 
the family history and the fact that the tendency to bleed in 
hemophilia almost never appears before the end of the first 
year. Larrabee, writing in 1906, was able to collect but 
thirty-six cases of hemorrhage in the newborn due to hemo- 
philia, and in all but two of these there was a family history 
of the disease. The diagnosis is, therefore, Hemorrhagic 
Disease of the New-born. 

Prognosis. The condition is, in general, a very serious one. 
Sixty per cent, or more, of the patients die, one half of them 
in the first twenty-four hours after the onset of the bleeding. 
If they survive a week they almost invariably recover. The 
symptoms cease in the first five days in two thirds of the 
cases that recover. The cases in which there is hemorrhage 
from the gastro-intestinal tract and in which there is a high 
temperature are more serious than those in which there is 
no gastro-intestinal hemorrhage and in which the tempera- 
ture is low. 

The following prognosis seems justified in this instance. 



lOO CASE HISTORIES IN PEDIATRICS. 

The baby has a very serious disease. It is impossible to say 
whether or not the hemorrhages will recur or others appear. 
The outlook is, however, fairly good because he has already 
lived seventeen hours, there has been no hemorrhage for 
several hours, the bleeding is all external where it can be 
reached, and the temperature is normal. Every day that he 
lives increases his chances materially. There is no reason to 
fear recurrence in after years because this is a self-limited 
condition and not the disease hemophilia. 

Treatment. Little is definitely known as to the etiology 
of hemorrhagic disease of the new-born. In fact, it is very 
probable that it is not a definite disease but merely a symp- 
tom-complex due to a variety of causes, the most common of 
which is presumably sepsis. No constant changes have been 
found in the blood. In some instances the coagulation of the 
blood is normal; in others, delayed; in others, absent. It is 
certain, however, that when there is an abnormality in the 
coagulation of the blood, it is not due to a lack of calcium or 
to the presence of any substance which prevents or inter- 
feres with coagulation. The defect, if there is one, is due to 
a lack of some substance necessary to coagulation, not to the 
presence of some substance inhibitory to coagulation. It is 
very possible, moreover, that in some instances, or perhaps 
in all, the cause of the hemorrhage is some local defect in the 
blood-vessels rather than an abnormality in the blood. 

Fortunately, much more is known about the treatment of 
hemorrhagic disease of the new-born than as to its etiology. 
Most of the methods employed in the past in the treatment 
of this disease have been proved to be useless. Ergot and 
iron cannot, of course, have any effect in increasing the 
coagulability of the blood or remedy a defect in the blood- 
vessels. Adrenalin has practically no action, unless given 
intravenously. Its action is then general, not local, and the 
increase of the blood-pressure would tend to increase rather 
than to diminish the bleeding. Gelatine does not increase 
the coagulability of the blood either in vitro or in vivo. 
There is no lack of calcium salts in the blood in these cases, 
and therefore the administration of calcium salts can do no 
good. 



DISEASES OF THE NEW-BORN. lOI 

The treatment in these cases consists in the introduction 
of fresh animal or human serum or human blood, either 
subcutaneously or intravenously. It is difficult to under- 
stand theoretically how these procedures can do good. 
Practically, however, there is no question as to their efficacy. 
The simplest method of treatment is to give fresh rabbit 
serum, horse serum or human serum subcutaneously, in 
doses of from one-half to one ounce. Horse serum may 
be used in the form of antitoxin, if no other is available. 
Being old, however, it is not as useful as the fresh serum. 
Another simple method is to withdraw from one-half to one 
ounce of blood from the donor's vein and inject it sub- 
cutaneously into the baby's buttocks or back. 

Transfusion is the most effectual way of treating these 
cases. It not only supplies all the blood elements, but also 
provides blood to take the place of that which has been lost. 
When transfusion is done, however, it is necessary to be 
sure that the donor's blood does not produce hemolysis. 
Direct transfusion is a serious and very difficult operation 
when the recipient is an infant. Indirect transfusion, by 
Lindeman's canula-syringe method, or by the use of Kimp- 
ton's tubes and their modifications, is a comparatively simple 
operation. This being the case, there is no reason why 
transfusion should not be used early and not left to be the 
last resort, as in the past. 

This baby has already had an injection of rabbit serum. 
If the hemorrhage recurs, it should be repeated in six or 
eight hours and again at the same interval, if necessary. 
If the serum fails to restrain the hemorrhage in- these doses, 
or if at any time the baby's condition is becoming at all 
critical, transfusion should be done. 

Locally, the adrenalin solution should be continued in 
connection with pressure. If this fails to stop the bleeding 
the strength of the solution may be increased to i-i,ooo, or 
the dry powder used. If this is not effective, Monsel's salt 
and pressure may be tried or thromboplastin. 

The baby should be given from one to two teaspoonfuls of 
a mixture of one part of breast milk to three parts of water, 
or whey, every hour. 



102 CASE HISTORIES IN PEDIATRICS. 

CASE 1 8. Joanne W. was the second child of healthy 
parents. The other child, a boy, was well. Her father had 
never shown any symptoms of hemophilia, except that on 
one occasion, when he had had several teeth extracted, the 
gums oozed for three or four hours. Two of his brothers 
had, however, died within the first two or three days of life 
from hemorrhages of some sort, and the first child of his 
sister, a girl, had died of hemorrhages when two days old. 
Joanne was born at noon, December i6, after a normal labor, 
seemed normal at birth and weighed nine and one-quarter 
pounds. She had three movements, consisting of meconium, 
in the first thirty-six hours after birth and passed urine freely. 
She took the breast well during the night of December i8. 
At 7.30 A.M., December 19, she vomited about half a teaspoon- 
ful of bright blood, and at 9.30 a.m. a little more than half a 
teaspoonful of bright blood. At 11.20 a.m. she had a move- 
ment from the bowels which soaked through three napkins, 
her nightgow^n and on to the bed. This movement was mostly 
black, but contained a little bright blood and a few clots. 
At 12.30 P.M. she vomited a little more blood and again at 
1.30 P.M. She was given 15 cc. of rabbit's serum subcutane- 
ously at 3 P.M. At 3.45 p.m. she had a discharge of dark 
blood from the bowels, which wet through two napkins. She 
was given 15 cc. of rabbit's serum subcutaneously at 4.15 
p.m., and during the afternoon and early evening took three 
ounces of a thin gelatin solution by mouth. At 9.15 p.m. she 
had a movement from the bowels, consisting mostly of bright 
blood, which wet through several diapers and her nightgown. 
She had not seemed affected by the loss of blood before this 
last movement. Since then, however, she had begun to look 
pinched and a little blanched, and her pulse had gone up to 
160. Her cry remained strong, however, and there was no 
sighing or restlessness. She was seen in consultation at 
10.45 p.m. 

Physical Examination. She was well developed and nour- 
ished, but had evidently lost weight. She looked pinched 
about the mouth and was a little pale. Her cry was strong. 
The anterior fontanelle was level. There was no rigidity of 
the neck. The mouth and throat showed no bleeding point. 



DISEASES OF THE NEW-BORN. IO3 

The heart was normal. The lungs were normal in front. The 
back was not examined. The liver was palpable two cm. 
below the costal border in the nipple line. The spleen was 
not palpable. The stump of the cord was healthy. The 
rectal temperature was 99.5° F.; the pulse, 156. The ex- 
tremities were not examined. She had another movement, 
consisting of about two tablespoonfuls of dark blood, during 
the examination. 

Diagnosis. Hemorrhage from congenital syphilis can be 
excluded on the good family history, the good general condi- 
tion and the absence of all other evidences of syphilis. Hem- 
orrhage from general sepsis can be excluded on the practically 
normal temperature, the good general condition and the 
absence of jaundice, cyanosis and other signs of sepsis. The 
two conditions which must be seriously considered are hemo- 
philia and hemorrhagic disease of the new-born. The history 
of the death of a child of an aunt and of two of the father's 
brothers from hemorrhage during the first few days of life 
and of the somewhat prolonged bleeding from the gums in the 
father suggests hemophilia. The bleeding from the gums in 
the case of the father was comparatively slight, however, and 
had never been considered unusual until this baby began to 
have hemorrhages. There are only thirty-six cases on record 
of hemophilia in which the symptoms appeared in the first few 
days of life. It seems far more probable, therefore, that the 
father's brothers and his niece died of hemorrhagic disease of 
the new-born than of hemophilia. The fact that hemophilia 
almost never occurs in the female makes it still more probable 
that the girl died of hemorrhagic disease of the new-born. 
Further points against hemophilia in this instance are that 
the disease is transmitted through the female, not through the 
male, and that the baby is a girl, not a boy. The hemor- 
rhages in hemophilia seldom occur, moreover, spontaneously, 
while the hemorrhages in hemorrhagic disease of the new- 
born are almost invariably, as in this instance, spontaneous. 
The diagnosis of Hemorrhagic Disease of the New-born 
seems, therefore, justified. 

Prognosis. There is no medicinal treatment which offers 
any prospect of relief. Rabbit*s serum has not been of any 



104 <^SE HISTORIES IN PEDIATRICS. 

benefit. The chances of the spontaneous cessation of the 
hemorrhage are practically nil. She will almost certainly 
die within the next thirty-six hours unless a transfusion is 
done. 

Treatment. The treatment is immediate transfusion. 
The most available donor is the father, since it is hardly wise 
to subject the mother to a long and serious operation and 
inadvisable to call on anyone else, because of the danger of 
hemolysis. The points already detailed in discussing the 
diagnosis seem sufficient to prove that he is not a hemophiliac 
and that it is safe to use his blood. (See Case 17.) 



DISEASES OF THE NEW-BORN. IO5 

CASE 19. William S. was the first child of healthy parents. 
He was born September 7. His father denied having had 
syphilis and there was no reason to suspect that his mother 
had had it. There had been no miscarriages. He was 
delivered at full term by high forceps, was normal at birth 
and weighed seven and three-quarters pounds. His mother 
had plenty of milk. He nursed well until September 1 1 , after 
which he took the breast very poorly. He did not vomit. 
The stools consisted of meconium during the first three days, 
since when he had had three or four brownish-yellow stools, 
containing many small soft curds and a little mucus, daily. 
The cord came off September 13, leaving a healthy navel. 
His temperature rose to 103° F. on September 10, and had 
ranged between 102° F. and 103.5° F. ever since. His mouth 
became sore September 12, and he had been more or less rigid 
since then. He had had no convulsions. He had lost weight 
and strength very rapidly during the last few days. He was 
seen in consultation September 15, when eight days old. 

Physical Examination. He was considerably emaciated 
and his face looked pinched. The anterior fontanelle was 
sunken and the bones of the skull overlapped. The pupils 
were equal and reacted to light. The tongue, lips and mouth 
were mxuch reddened and in places covered by a thin pseudo- 
membrane. The heart, lungs and abdomen were normal. 
The navel was healthy. The lower border of the liver was 
palpable two cm. below the costal border in the nipple line. 
The spleen was not palpable. The genitals were normal. 
The extremities were normal. There was m.oderate rigidity 
of the neck and extremities, with slight retraction of the head. 
There was no rigidity of the lower jaw. The knee-jerks were 
equal and exaggerated. Kernig's sign was absent. There 
was no enlargement of the peripheral lymph nodes. The tips 
of the ears, the end of the penis and the heels and elbows were 
excoriated. There was also a profuse pustular eruption on 
the neck, as well as an occasional pustule on the body. The 
skin about the anus was normal. The rectal temperature 
was 103.2° F.; the pulse, 180; the respiration, 48. 

Cultures from the throat showed the staphylococcus aureus 
as the predominating organism and no Klebs-LoefHer bacilli. 



I06 CASE HISTORIES IN PEDIATRICS. 

Diagnosis. The diagnosis in this instance lies between con- 
genital syphilis and septic infection of the new-born. Tetanus, 
which is suggested by the general rigidity, can be excluded on 
the normal condition of the navel, and on the absence of rigidity 
of the jaw and of convulsions. Cerebral hemorrhage, as the 
result of injury at birth, and meningitis are also suggested by 
the rigidity. The former can be ruled out on the persistent 
high temperature, the sunken fontanelle, the late develop- 
ment of the rigidity and the local evidences of septic infection, 
while the sunken fontanelle and the evidences of local infec- 
tion make the latter most improbable. Rigidity of the neck 
and extremities is, moreover, a very common symptom in the 
new-born whenever they are seriously ill, no matter what the 
trouble, and is presumably merely an exaggeration of the 
normal congenital muscular hypertonia. It is of no assist- 
ance, therefore, in the diagnosis between congenital syphilis 
and septic infection. The sore mouth and the skin lesions 
suggest syphilis. The lesions of the mouth and skin are, 
however, in no way characteristic of syphilis. There are no 
mucous patches about the anus and the palms and soles are 
clear. The family history is good, there have been no mis- 
carriages, the baby was born at full term, there is no enlarge- 
ment of the liver and spleen, the genitals are normal and the 
temperature is higher than would be expected in syphilis. It 
seems justifiable, therefore, to exclude syphilis as the cause of 
the illness. There is nothing about the history and physical 
examination which is inconsistent w4th a septic infection ; in 
fact, they are both most characteristic of it. A positive 
diagnosis of Septic Infection of the New-born is, there- 
fore, justified. 

Prognosis. The prognosis is practically hopeless. He 
will almost certainly die within the next forty-eight hours. 

Treatment. The treatment can be only symptomatic. 
His mouth must be kept clean by swabbing it with a 4% 
solution of boracic acid or with a wash prepared with 5 parts 
of borax, 20 parts of glycerin and 80 parts of water. He 
should be fed every one and one-half hours with from two to 
four drachms of a mixture of equal parts of his mother's 
milk and water, given with a Breck feeder or a dropper. He 



DISEASES OF THE NEW-BORN. I07 

should also be given y (^r^ of a grain of strychnia every three 
hours and, if necessary, caffeine-sodium benzoate, in doses of 
Y6 of a grain, in addition. A dressing of boracic acid oint- 
ment should be applied to the excoriated areas and boracic 
acid powder to the neck. 



I08 CASE HISTORIES IN PEDIATRICS. 

CASE 20. Frederick G. was the second child of healthy 
parents. He was born at full term, December 29, after a 
rapid labor at which, in the absence of both physician and 
nurse, the grandmother officiated. He was normal at birth 
and weighed seven and one-half pounds. The cord came off 
January 3. Reddening and thickening about the navel, 
accompanied by a foul, thin, glairy discharge, was noticed 
January 9. There had been but little change in the local 
condition since then, although the physician in charge had 
pulled a slough, an inch long and as large around as a slate 
pencil, from the navel, January 16. He had taken the breast 
well until January 15, since when he had been given small 
quantities of his mother's milk, diluted with water, from 
the bottle. He began to vomit January 18, the vomitus 
being green. He had had ten or twelve loose, green stools, 
containing small curds and mucus, daily since January 
10. The rectal temperature had ranged between 102° F. 
and 103° F. since January 17; it had not been taken before. 
He had lost weight and strength very rapidly during the 
last forty-eight hours. He was seen in consultation Jan- 
uary 19. 

Physical Examination. He was considerably emaciated. 
The skin was pale with a decided yellow tinge. He looked 
and acted very sick. The anterior fontanelle was depressed 
and the bones of the skull overlapped. The tongue was con- 
siderably coated and the whole mouth reddened. The heart 
and lungs were normal. There was a round and tender 
swelling, about the size of one-half of an English walnut, 
about the navel. There was an opening, the size of a slate 
pencil, in the centre, from which a foul, glairy material could 
be squeezed. A probe could be run about, parallel with the 
surface, for an inch in all directions, but no opening into the 
deeper tissues or abdomen could be found. The abdomen 
showed nothing else abnormal. The lower border of the liver 
was palpable two cm. below the costal border in the nipple 
line. The spleen was not palpable. The extremities were 
normal and there was no enlargement of the peripheral lymph 
nodes. The rectal temperature was 102.6° F.; the pulse, 
180; the respiration, 48. * 



DISEASES OF THE NEW-BORN. ICQ 

Diagnosis. The diagnosis of Omphalitis and Septic In- 
fection OF THE New-born is plain. There is no evidence of 
a direct extension of the inflammatory process into the abdo- 
men or along the vessels to the liver. The infection must be, 
therefore, a general one. 

Prognosis. The outlook is practically hopeless. There is 
not one chance in one hundred of recovery. He will prob- 
ably not live more than two or three days. 

Treatment. The inflammatory area at the navel should 
be opened up, cleaned out and dressed with a -s^Att solution 
of corrosive sublimate. He should be given one-half an ounce 
of a mixture of two parts of his mother's milk, one part of 
lime water and one part of water every one and one-half 
hours. He should also be given xTnny of ^ grain of strychnia 
every three hours. This may be helped out from time to 
time, if necessary, by caffeine-sodium benzoate, in doses of 
one-sixteenth of a grain, given subcutaneously. 



no CASE HISTORIES IN PEDIATRICS. 

CASE 21. Baby G. was born at full term after a normal 
labor. He seemed healthy at birth but was not carefully 
examined. He was taken care of by a woman ignorant of the 
ordinary rules of cleanliness. The cord came off on the 
seventh day. The navel was healthy and at no time, before 
or after, was there any redness or inflammation about it. 
He was breast-fed and did very well until he was five days 
old, when he began to vomit a little and act as if he had pain 
in the abdomen. The vomiting and pain continued and 
increased in severity. He also began to have two or three 
loose yellow movements, containing fine curds and having a 
foul odor, daily. When he was nine days old a swelling, which 
seemed tender, was noticed in the epigastrium. The swelling 
in the epigastrium increased and by the twelfth day the 
whole abdomen was distended. He had apparently begun 
to have fever on the eighth day, but the temperature had not 
been taken. He was seen in consultation when two weeks 
old. 

Physical Examination. He had evidently lost much weight 
and his color was pasty. His face bore an expression of 
suffering. The fontanelle was depressed. There w^as no 
rigidity of the neck. The pupils were equal and reacted to 
light. The tongue was dry and covered with a brownish 
coat. The heart and lungs were normal. The upper border 
of the liver flatness in the nipple line was at the fourth rib; 
the lower border was not palpable. The spleen was not 
palpable. The navel was healthy and there was no redness 
about it. The abdomen was generally considerably dis- 
tended, but distinctly more so in the epigastrium. It was 
everywhere tympanitic, except over an area, the size of a 
silver dollar, in the median line midway between the tip of 
the ensiform and the navel. There was a marked sense of 
resistance in and about this area, but no definite muscular 
spasm. Tenderness was general throughout the abdomen, 
but much more marked over the resistant area in the epigas- 
trium. There was no dullness in the flanks and no fluid 
wave. The legs were drawn up on the abdomen and exten- 
sion caused additional pain. It was impossible to determine 
the presence or absence of the knee-jerks or Kernig's sign 



DISEASES OF THE NEW-BORN. Ill 

because of the baby's resistance. There was no enlargement of 
the peripheral lymph nodes. The rectal tem_perature was 
104^ F., the pulse 160, the respiration 60. 

Diagnosis. The trouble is undoubtedly located in the 
abdomen. The liver is displaced upward. The fact that the 
baby is breast-fed and the mildness of the symptoms of in- 
digestion in comparison with the high temperature, poor 
general condition and marked local symptoms show that the 
trouble is outside the gastro-intestinal tract. The situation 
of the local symptoms and the age of the baby make ap- 
pendicitis very improbable. The two possibilities are an 
inflammatory process, probably a localized abscess in the 
epigastrium, or a general peritonitis. The localization of the 
physical signs in the epigastrium and the absence of general 
muscular spasm and free fluid in the abdomen are much 
against general peritonitis and in favor of a localized abscess. 
A white count was not made because it could not help in the 
diagnosis, since both conditions are associated with leucocy- 
tosis. An inflammatory process in the upper or middle abdo- 
men at this age is almost invariably due to infection through 
the navel. The navel in this instance shows no signs of 
inflammation at present, and has shown none in the past. 
This does not rule out infection through the navel, however, 
as it is not uncommon for this to occur without causing any 
local manifestations. The known ignorance and the unclean- 
liness of the woman who took care of the baby make an 
infection through the navel seem even more likely. The 
most reasonable diagnosis is, therefore, a localized inflam- 
matory process, probably an abscess, in the epigastrium, as 
the result of an infection through the navel, i. e., a Septic 
Infection of the New-born. 

Prognosis. The prognosis is hopeless without an operation, 
practically hopeless with one. 

Treatment. The only treatment which offers any chance 
of recovery is an immediate laparotomy. 



112 CASE HISTORIES IN PEDIATRICS. 

CASE 22. Constance H. was born January 5 at full term, 
after a normal labor, and was normal at birth. Her mother 
had an uneventful convalescence, without any signs of sepsis, 
and had a plentiful supply of milk. There had been no irri- 
tation of the nipples or inflammation of the breasts. She 
did perfectly well until January 24, when she did not take the 
breast well, but did not seem sick in other ways. She was 
seen by her physician the next morning. He found nothing 
abnormal on physical examination, but a rectal temperature 
of 102° F. She took the breast well again during that day. 
The next morning, the twenty-sixth, her upper lip was con- 
siderably swollen and reddened. The swelling extended to 
the lower lip during the day, and during the night to the 
right cheek. The whole of the right cheek was involved on 
the twenty-eighth, but the swelling of the lips had dimin- 
ished so much that she was able to nurse again without 
difficulty. The swelling extended during the twenty-ninth 
to the right ear and side of the head. The rectal temperature 
had ranged between 102.5° F. and 104.5° F. She had not 
vomited and had had normal movements. She was seen in 
consultation at 5 p.m., January 29. 

Physical Examination. She was well developed and nour- 
ished and of good color. Her cry was strong. The anterior 
fontanelle was level. There was no rigidity of the neck. 
The pupils were equal and reacted to light. There was no 
nasal discharge. The mouth was healthy. Both the upper 
and lower lips were slightly swollen, but not reddened. The 
whole of the right side of the face was somewhat swollen and 
slightly reddened. The right ear was much swollen and 
reddened, as was also the lower part of the right side of the 
head. The edge of the swelling about the ear and side of the 
head was raised and easily distinguishable by its induration 
and color from the surrounding tissues. The swelling was 
not especially tender. The heart, lungs and abdomen were 
normal. The liver was palpable two cm. below the costal 
border in the nipple line. The spleen was not palpable. 
The navel was healthy. The extremities were normal. 
There was no spasm or paralysis. The knee-jerks were equal 
and normal. Kernig's sign was absent. There was no en- 




Antero-posterior view. 




Lateral view. 



Frank G. Case 23. 



DISEASES OF THE NEW-BORN. II3 

largement of the peripheral lymph nodes. The rectal tem- 
perature was 104.5° F-» the pulse, i6o; the respiration, 36. 

Diagnosis. The progressive extension of the swelling, the 
improvement in the parts first affected and the elevated and 
sharply defined edge are so characteristic of Erysipelas, that 
there can be no doubt that this is the diagnosis. 

Prognosis. At least 90% of young babies affected with 
erysipelas die, erysipelas at this age being almost invariably 
migratory in character. Babies that survive the acute stage 
of the disease are, moreover, very likely to die, apparently 
from weakness, within the next one or two weeks. The 
chances are, therefore, very much against recovery in this 
instance, in spite of the baby's good general condition at 
present. 

Treatment. There is no local treatment which has much, 
if any, effect on the progress of the disease. Ichthyol has as 
much, if not more action than any of the others. A 30% 
ointment of ichthyol, prepared with vaseline, should be ap- 
plied every three or four hours to the affected areas. There 
is no drug which has any effect whatever on the local condi- 
tion. In the more chronic cases vaccines sometimes seem to 
be of assistance. If the process continues to extend in this 
instance, it will perhaps be advisable to use vaccines after 
another week. The most important methods of treatment 
are regulation of the diet and hygienic surroundings. The 
baby is now on the breast. This food cannot be improved 
upon. Great care must be taken, however, to prevent in- 
fection of the mother's nipples and breasts. She should be 
given all the fresh air and sunlight possible. No stimula- 
tion is required at present. 



SECTION III. 
DISEASES OF THE G ASTRO-ENTERIC TRACT. 

The classification which follows is that adopted by the 
Department of Pediatrics of the Harvard Medical School. 
It is open to many objections, but, on the whole, seems to 
the author more satisfactory than any other. It is based, 
as far as possible, on etiology. Being different from other 
classifications, it is given in order that the terms used later 
may be intelligible. 

The author is in the habit of roughly dividing the diseases 
of the gastro-enteric tract, associated with diarrhea, in the 
following manner. He realizes that this division is arbitrary 
and open to much criticism, but it seems to him reasonably 
satisfactory from a clinical standpoint and as a basis for 
treatment. 

When there is merely an increase in the number of move- 
ments, with a diminution in the consistency, no fever and 
practically no other symptoms, he describes the condition as 
nervous diarrhea and attributes it to causes acting directly 
or indirectly on the central nervous system. 

Under normal conditions there is an equilibrium between 
the work to be done and the power to do it, that is, between 
the food which is to be digested by the intestinal secretions 
and the secretions. If there is a disturbance of this equi- 
librium from an increase in the amount of work to be done, 
as occurs when the amount of food is too large, or there is an 
excess of one or more of the individual food elements, the 
resulting disturbance is designated as indigestion from over- 
feeding or from one of the food elements, fat, carbohydrate, 
proteids or salts, as the case may be. It is evident that the 
equilibrium may also be disturbed as the result of a diminu- 
tion in the amount or digestive power of the secretions, as 
occurs when the child is depressed from any cause or is suf- 
fering from some other disease. Under these conditions the 

115 



Il6 CASE HISTORIES IN PEDIATRICS. 

symptoms will be the same and the treatment of the dis- 
turbance of digestion the same as when the disturbance of 
equilibrium is due to an excess of food. The disturbance of 
digestion may be either acute or chronic. Bacteria play no 
part in its etiology. The stools are increased in number and, 
as a rule, diminished in consistency. They also show the 
evidences of incomplete digestion of one or more of the in- 
dividual food elements, the character of the stools depending 
on what element or elements of the food are absolutely or 
relatively in excess. 

If fermentation takes place in the intestinal contents as 
the result of bacterial action, new symptoms develop. The 
stools are usually changed in color and odor and show more 
marked disturbance of digestion. Other symptoms, such as 
fever, may appear as the result of toxic absorption. This is 
the class of cases known as indigestion with fermentation. 
It is more often acute than chronic. It is assumed that in 
pure cases there is no inflammation of the intestine and no 
entrance of bacteria into the circulation. It is self-evident 
that the line between indigestion and indigestion with fer- 
mentation must necessarily be a very indefinite one. 

If the bacteria cause inflammatory changes in the intestinal 
wall there is usually a further change in the character of the 
stools, which become very numerous and are composed 
mainly of mucus and blood. The temperature is usually 
moderately and constantly elevated, and the constitutional 
symptoms are much more marked. It is probable that in 
many instances bacteria traverse the intestinal wall and 
enter the circulation. This condition is called infectious 
diarrhea. It is again evident that the line between indi- 
gestion with fermentation and infectious diarrhea cannot be 
too sharply drawn. 

Cholera infantum, in which there is a very large number 
of profuse watery movements, is presumably a variety of 
infectious diarrhea. 



DISEASES OF GASTRO-ENTERIC TRACT 



"7 



CLASSIFICATION 



Developmental 



Mechanical 



New Growths 
Traumatic 



Nervous 



or 
DISEASES OF THE GASTRO-ENTERIC TRACT 

Malpositions 
MaKormations 

Contraction of the Stomach 

Dilatation of the Stomach 

Pyloric Stenosis 

Dilatation of the Colon 

Volvulus 

Intussusception 

Hernia 

Fissure of Anus 

Prolapse of Rectum 

Hemorrhoids 



Foreign Bodies 
Corrosive Gastritis 
Peptic Ulcer 

Vomiting 
Diarrhea 



Disturbances of Digestion 



1. Overfeeding as a whole 

2. Overfeeding with various food elements 

a. Fat 

b. Carbohydrates 

c. Protein 

d. Salts 

3. Indigestion with Fermentation 



Infections 



Unclassified 



Gastritis 
Infectious Diarrhea 

a. Dysentery Bacillus 

b. Gas BaciUus 

c. Other Organisms 

Proctitis 

Appendicitis 

Fistulae 

Recurrent Vomiting 
Constipation 
Incontinence of Feces 
Intestinal Parasites 



Il8 CASE HISTORIES IN PEDIATRICS. 

CASE 23. Frank G., six years old, was the second child 
of markedly neurotic parents. His brother, who was nine 
years old, would not eat meat, milk or eggs. He was well up 
to the age of two years when he had the whooping-cough, in 
which he had frequent attacks of vomiting. Since then he 
had had recurrent attacks of vomiting, lasting for weeks at a 
time. At the beginning of an attack he would vomit solid 
food, but would retain liquids. After a few days he would 
vomit liquids and finally would retain nothing. He would 
then gradually improve and get back to his usual routine. 
He would never, however, even between attacks, swallow 
hard solids, like meat, but swallowed bread, after chewing it 
thoroughly, and soft solids without difficulty. The vomiting 
always occurred immediately after taking food. If the food 
was not vomited within a few minutes after it was taken, it 
was retained. He never vomited any food which had been 
taken some time before or which was decomposed. He never 
had any pain. The bowels were constipated during the 
attacks, but at other times the movements were normal. 
He had been through a course of stomach washing six months 
before he was seen in consultation. An adult stomach tube 
was passed at that time without difficulty. There was no 
evidence of gastric stasis and the stomach contents showed 
no evidences of indigestion. His present attack was the 
most severe that he had ever had. He had retained practi- 
cally nothing for a number of days, although he had been very 
hungry and had taken food eagerly. Even water had been 
vomited immediately during the last few days. Thirst was 
consequently extremely troublesome. He had been given 
nutrient enemata for several days, but had, nevertheless, lost 
rapidly in flesh and strength. 

Physical Examination. He was thin and pale. He was 
perfectly clear mentally. He was constantly asking for water. 
He would take about two ounces eagerly, but would vomit 
it up immediately with considerable retching. He would at 
once take another two ounces and vomit it up and would 
apparently have kept on doing this indefinitely. His tongue 
was clean. The throat was normal to both inspection and 
palpation. When water was swallowed gurgling could be 



DISEASES OF GASTRO-ENTERIC TRACT. II9 

heard to the left of the spinous processes as far down as the 
sixth dorsal spine (normally it should be heard to the eighth 
or ninth). Nothing could be heard entering the stomach. 
An adult-sized stomach-tube was easily passed in seven 
inches from the incisor teeth, where it met an obstruction 
and could be passed no further. When a very little water 
was poured in, it was promptly vomited and evidently did 
not reach the stomach. The heart and lungs were normal. 
There was no dullness under the manubrium or in the middle 
back. The bronchial voice sound was not heard below the 
seventh cervical spine. Air entered both lungs alike. There 
was no evidence of pressure on veins or nerves within the 
thorax. There was no murmur under the manubrium, and 
the pulses were synchronous in both arms. The abdomen 
was sunken and entirely negative. The liver and spleen were 
not palpable. The extremities were normal. There was no 
spasm or paralysis. The knee-jerks were equal and normal. 
Kernig's sign was absent. There was no enlargement of 
the peripheral lymph nodes. 

The urine was high-colored, strongly acid, of a specific 
gravity of 1030, and contained no albumin or sugar. The 
sediment was abundant and composed of amorphous urates. 

Diagnosis. There is undoubtedly a narrowing of the 
esophagus about four inches above the cardia. This narrow- 
ing cannot be due to pressure from the outside, because of 
the duration of the symptoms and the absence of all signs of 
inflammation, new growth, aneurism or enlargement of the 
tracheobronchial lymph nodes. It cannot be due to cica- 
tricial contraction, because there is no history of any injury 
in the past. The duration and the intermittence of the 
symptoms, as well as the relatively good general condition, 
rule out a malignant growth, while these points in connection 
with the absence of other evidences of syphilis exclude a 
syphilitic growth. The facts that small quantities are 
vomited immediately, that several feedings are never retained 
and then vomited and that the vomitus is never decomposed 
show that there is no marked dilatation above the narrowing 
and no diverticular. The narrowing may be due, then, to a 
non-malignant constriction, to spasm, or to a combination 



120 CASE HISTORIES IN PEDIATRICS. 

of the two. The points in favor of an organic constriction 
are the permanent inability to swallow solid food, the firm 
resistance encountered by the stomach tube, the persistence 
of the symptoms in the present attack and the tender age 
of the patient. The points in favor of spasm are the neurotic 
family inheritance, the fact that his brother has always 
refused to eat certain kinds of food, the intermittence of the 
symptoms and the fact that a stomach-tube could be passed 
easily six months ago. The most reasonable explanation 
seems to be that he has always had a certain amount of 
organic constriction, that the obstruction has been exagger- 
ated at times by spasm and that the organic constriction has 
now increased so much that it practically obliterates the 
lumen. This diagnosis ought, however, to be verified by an 
examination with the Roentgen ray after the ingestion of 
bismuth paste. The accompanying Roentgenographs show 
the conditions found in this way by Dr. A. W. George. The 
diagnosis of Organic Stricture of the Esophagus is, there- 
fore, verified. 

Prognosis. The prognosis is hopeless without surgical in- 
tervention. He can, of course, be kept alive for a short time 
by nutrient enemata and the subcutaneous injection of salt 
solution. Death must, however, eventually result from starv- 
ation. If the stricture is dilated, either from above or below, 
the cure ought to be a permanent one and recovery complete. 

Treatment. The treatment is, of course, the dilatation of 
the stricture by the passage of bougies. It is possible that 
he can be made to swallow a thread and that bougies can be 
passed along it. This is a difficult procedure in a child, 
however, and it will in all probability be necessary to do 
a gastrotomy and pass the first bougie from below upward. 



DISEASES OF GASTRO-ENTERIC TRACT. 121 

CASE 24. David R. was born at full term, February i6, 
after a normal labor. He seemed normal at birth, but was 
not weighed. The breast-milk came in quickly, was suffi- 
cient in quantity and he took it well. When four days old 
he began to vomit after nearly every feeding, the vomiting 
occurring immediately after nursing. He usually cried at 
the time of the vomiting and for ten or twenty minutes after 
it, as if in pain. When two weeks old, condensed milk and 
lime water and barley water and lime water were tried 
in place of the breast-milk. Both were vomited and he was, 
therefore, put back on the breast. The vomiting from this 
time on was explosive. Beginning March 13, ten drops of 
lime water and one teaspoonful of water were given before 
each nursing. The vomiting had not been quite as severe 
since then. The bowels had not moved spontaneously since 
he was a week old. Suppositories were ineffectual, but a 
movement had been obtained daily from castoria. These 
had been very small, often being merely a dark brown stain 
on the napkin. He had not been weighed, but was thought 
to have lost weight steadily since he was a week old. He 
was admitted to the Infants' Hospital, March 17, when a 
month old. 

Physical Examination. He was small, emaciated and 
feeble, but his color was fair. The skin was not very dry, 
but there was a little general rigidity. The anterior fon- 
tanels was two and one-half cm. in diameter and sunken. 
The posterior fontanelle was still open. The bones of the 
skull did not overlap. The mouth was clean and moist. 
The heart and lungs were normal. The liver was just pal- 
pable in the nipple line. The spleen was not palpable. The 
abdomen was sunken and nothing abnormal could be de- 
tected in it when the stomach was empty. He was given a 
bottle of whey and after he had taken an ounce the stomach 
was distinctly palpable. When he had taken two ounces 
the stomach felt hard, but there was no visible peristalsis. 
By the time he had taken two and one-half ounces the pylo- 
rus could be felt to contract and harden, being as large as the 
last joint of the little finger. This was followed by marked 
explosive vomiting of all that he had taken. The pylorus 



122 CASE HISTORIES IN PEDIATRICS. 

could then be felt to relax and finally entirely disappear. 
This sequence recurred every time that the stomach was 
filled. There was no visible peristalsis at any time. The 
genitals were normal. The extremities showed nothing ab- 
normal. There was no paralysis. The knee-jerks were equal 
and lively. Kernig's sign was absent. There was no en- 
largement of the peripheral lymph nodes. He weighed four 
pounds. 

The urine was pale in color, clear, slightly acid in reaction 
and contained no albumin. 

The stool was composed of bile and water with a very 
little mucus. 

Diagnosis. The slight general rigidity suggests, to a cer- 
tain extent, some cerebral lesion as the cause of the vomiting. 
The rigidity can be equally well explained, however, by the 
age of the baby and the disturbance of nutrition, both of 
which are often accompanied by muscular hypertonia. The 
positive findings in the abdomen prove, moreover, that the 
condition is a local one. Chronic indigestion is very un- 
common in breast-fed babies. It can be excluded in this 
instance by the explosive vomiting, the pain during and after 
vomiting, the lack of milk remains in the movements, and 
the presence of a palpable tumor at the pylorus. The diag- 
nosis lies, therefore, between spasm of the pylorus and ste- 
nosis of the pylorus. 

The fact that the baby is breast-fed is a point in favor of 
stenosis, while the pain during and after vomiting is in favor 
of spasm. The explosive vomiting, the constipation and the 
progressive failure are symptoms common to both conditions 
and are, therefore, of no importance in differential diagnosis. 
The presence of a tumor points strongly towards stenosis, 
because a tumor is much more often palpable in stenosis 
than in spasm. The intermittent contraction and relaxa- 
tion of the tumor never occurs in stenosis, however, and is 
most characteristic of spasm. The presence of this sign 
justifies, therefore, a positive diagnosis of Spasm of the 
Pylorus. 

Prognosis. His general condition is fair under the cir- 
cumstances; the disease is curable; he has had no rational 
treatment. The outlook is, therefore, reasonably good. 



DISEASES OF GASTRO-ENTERIC TRACT. 1 23 

Treatment. He should be taken off the breast for the 
present. The breasts must not be allowed to dry up, how- 
ever, for he will probably be able to take breast-milk again 
later. The most suitable food for him at present is one 
which has but little stimulant action on the gastric secre- 
tions and which will leave the stomach quickly in the liquid 
form. Whey is such a food. The stomach becomes pal- 
pable and hard from contraction when he has taken but an 
ounce. He ought not, therefore, to be given more than half 
an ounce at a time. If given such a small amount at a 
feeding, he must be fed at short intervals. Otherwise he will 
not get enough food. He should, therefore, be given sixteen 
feedings, at one and one-half hour intervals, of one-half an 
ounce of whey. It has been claimed, and there is some evi- 
dence to show that it is true, that rectal injections of salt 
solution diminish the gastric secretions and hence gastric 
spasm. It will be well, therefore, to give an ounce of physi- 
ological salt solution with a rectal tube every four hours. 
If it does not have this action, it will, at any rate, supply 
needed water to the tissues. 

If the whey is retained, as it probably will be, the amount 
can be increased to 20 or 25 cc. at a feeding. The caloric 
value of this food is, however, entirely insufficient to cover 
his needs and must soon be increased. The following prin- 
ciples must be remembered in strengthening his food: fat 
delays the emptying of the stomach; carbohydrates leave 
the stomach quickly; casein is coagulated by rennin, while 
whey proteids are not; alkalies delay the action of rennin 
and allow the passage of the milk into the intestine before it 
is coagulated. A suitable modification for him will be, there- 
fore, one containing 1% of fat, 7% of milk sugar, 0.75% of 
whey proteids and 0.25% of casein, with lime water 50% of 
the milk and cream in the mixture. If this is well borne he 
may then be given a mixture containing 1.50% of fat, 7% of 
milk sugar, 0.75% of whey proteid and 0.25% of casein, with 
lime water 50% of the milk and cream or, better, equal parts 
of breast-milk and a 7% solution of milk sugar. 



124 CASE HISTORIES IN PEDIATRICS. 

CASE 25. Robert M., the second child of healthy parents, 
was born at full term after a normal labor. He was normal at 
birth and weighed six pounds and twelve ounces. His mother 
had a plentiful supply of milk and he was nursed regularly at 
two-hour intervals. He vomited a little from the first, but 
when two weeks old began to vomit much more. This was 
at first attributed to indiscretions In diet on his mother's 
part, but continued to increase after her diet was carefully 
regulated. It was then thought that he got too much milk, 
and the length of nursing was shortened to five minutes. 
This made no difference in the vomiting. A half-teaspoonful 
of lime water was then given with each nursing, but did not 
affect the vomiting. The mother was a healthy, vigorous 
woman, and it did not seem probable that the composition 
of the breast-milk was at fault, although it had not been 
examined. Whey, which was tried for twenty-four hours, 
was vomited more than the breast-milk. The vomiting some- 
times occurred immediately after nursing, but usually not for 
an hour or more. Sometimes several feedings were retained 
and then vomited together. The vomiting had recently been 
explosive. The bowels had moved regularly, but the move- 
ments had been small ; they were dark green in color and 
composed largely of mucus with a few fine curds. He acted 
hungry all the time and cried a great deal, apparently from 
hunger. He gained slowly in weight during the first three 
weeks up to seven pounds and twelve ounces. When seen in 
consultation, when five weeks old, he had dropped back to 
seven pounds and four ounces. 

Physical Examination. He was well developed and nour- 
ished and of good color. The fontanelle was level, and the 
bones of the skull did not overlap. His tongue was clean and 
moist. The heart and lungs were normal. The liver was 
palpable i cm. below the costal border in the nipple line. 
The spleen was not palpable. The extremities were normal. 
There was no spasm or paralysis; the knee-jerks were equal 
and normal. There was no enlargement of the peripheral 
lymph nodes. The examination of the abdomen was at first 
rather difficult because of the crying, and nothing abnormal 
was detected. The stomach was undoubtedly empty, as he 



DISEASES OF GASTRO-ENTERIC TRACT. I25 

had vomited a great deal about an hour before and had taken 
nothing since. It was thought that he would keep quieter if 
his stomach was filled and that perhaps something might be 
seen or felt then which could not be before. He was, there- 
fore, given two and one-half ounces of water, which he took 
greedily. The lower border of the stomach then reached to 
the navel, and very marked waves of peristalsis, running from 
left to right, appeared. A mass about the size of a marble was 
felt indistinctly in the region of the pylorus. He then vomited 
the whole of the water in one gush, the water striking the floor 
about three feet from the baby. The tumor could then be 
felt very distinctly while the baby was relaxed after the vomit- 
ing. He had a small movement, consisting of about half a 
teaspoonful of brownish mucus, during the examination. 

Diagnosis. The history in this instance is so typical of 
Infantile Pyloric Stenosis that it justifies, as far as any 
history without physical examination can, a positive diagnosis 
of this condition. The only other disease to be seriously 
considered is chronic indigestion. The appearance of vomit- 
ing in a breast-fed baby after two weeks, in which there had 
been only a little spitting up, the progressive increase of the 
vomiting, the failure to respond to regulation of the nursing, 
the explosive character of the vomiting and the small meco- 
nium-like stools containing almost no fecal residue, are not 
consistent with chronic indigestion. A cerebral lesion as 
the cause of the vomiting can be immediately ruled out on 
the general condition, the level fontanelle and the absence 
of spasm, paralysis and increased reflexes. 

The physical examination verifies, of course, the diagnosis 
made on the history. The enlargement of the stomach, the 
visible peristalsis and the palpable tumor are proof positive. 
The methods employed in the examination of the abdomen 
are worthy of attention. No examination of the abdomen 
can be considered complete, when there is a suspicion of 
stenosis of the pylorus, unless it is made with the stomach 
both full and empty. If peristalsis is not visible when the 
stomach is full, it can often be produced by stroking the 
epigastrium or flicking it with a towel wet in cold water, or a 
piece of ice. The author believes that a positive diagnosis of 



126 CASE HISTORIES IN PEDIATRICS. 

pyloric stenosis would have been justified in this case even if 
a tumor had not been felt. 

Prognosis. The prognosis without operation is hopeless; 
with an operation by a competent surgeon the outlook is 
very good, because of the baby's good general condition. 
The operations for this condition are aU so recent that there 
are almost no data as to what happens to these babies in 
after years. What data there are, however, go to show that 
their digestive powers are not impaired, that they develop 
normally and that their expectation of Hfe is not altered. 

Treatment. The only rational treatment in this instance 
is immediate operation. The usual operation in the past 
has been a posterior gastro-enterostomy. It is a dehcate 
operation, requiring special skill and considerable time. 
Slight variations in technic make the difference between 
success and failure, Kfe and death. No surgeon who has 
not done it before, or who has not had much experience in 
operating on small animals, should attempt it. A better 
and much simpler operation is the longitudinal incision of 
the pylorus down to the mucous membrane. This can be 
done in a very few minutes by any one having a reasonable 
amount of experience in abdominal surgery and is accom- 
panied by very little shock. The ultimate results are ap- 
parently as good as after gastro-enterostomy. 



DISEASES OF GASTRO-ENTERIC TRACT. 1 27 

CASE 26, Edward C, six years old, was the third child of 
healthy parents. The two other children were living and well 
and there had been no miscarriages. There was a history of 
tuberculosis in his father's family, but he had had no known 
exposure to it. He was born at full term, after a normal 
labor, was normal at birth and weighed seven pounds. He 
was constipated from birth. The physician, who attended 
him at this time, said that there was a growth about a finger's 
length up the bowel. The mother said that with her little 
finger she could just reach something which felt like a ring. 
An attempt was made to dilate this constriction by the intro- 
duction of the finger, first by the physician and then by the 
mother, once or twice a week during the first year. Nothing 
of the sort had been done since then. The constipation had 
continued up to the present time. Variations in the diet had 
no effect upon it. All sorts of drugs had been tried, but none 
of them had worked as well as enemata. He never had a 
movement without help. The stools were usually small in 
diameter, dark-colored and well digested. They were some- 
times in very small pieces, like sheep dung, but never in the 
form of large balls. There was sometimes a little mucus on 
the outside of the stools, but never any blood. The only 
time in his life that he had had loose movements was once 
when he had eaten a great many pears. He had had attacks 
of vomiting ever since he was weaned, when six months old, 
which were apparently due to blocking up of the bowels, as 
they always ceased when the bowels moved. His abdomen 
began to enlarge when he was two and one-half years old. 
It had, on the whole, grown steadily larger, although it varied 
in size from day to day. The swelling was at first most 
marked in the lower portion, but recently the upper portion 
had seemed the larger. There was at times visible peris- 
talsis. He very seldom had any pain, but often passed a 
great deal of gas from the anus. He had developed well in 
other ways. He cut two teeth when he was four months old, 
walked at sixteen months and talked early. He was active 
and was able to run about and play with the other boys, 
although he became short of breath if he exerted himself 
much. 



128 CASE HISTORIES IN PEDIATRICS. 

Physical Examination. He was tall and thin. The lips 
and nails were of good color. He was perfectly normal 
mentally. The tongue was clean, the teeth poor. The 
abdomen was enormous, the chest and extremities appearing 
like appendages to it. The heart was of normal size, but it 
was displaced a little upward and to the left. The sounds 
were normal. The lungs were normal. The upper border 
of the liver flatness was at the upper border of the fifth rib. 
The lower border of the liver dullness was two cm. above the 
costal border. The spleen was not palpable. The abdomen 
was enormously distended, the distention being greatest 
in the upper portion. The distention was at times uni- 
form; at others, slight waves of peristalsis were visible with 
deep sulci between them. The abdomen was everywhere 
tympanitic. There was no tenderness or muscular spasm 
and no tumors were felt. The following measurements were 
taken : 

Circumference of chest at nipples, 6i cm. 

Circumference of abdomen at navel, 64 cm. 

Circumference of abdomen at level of anterior superior 

spines, 55 cm. 

Greatest circumference of abdomen, 74 cm. 

The extremities were normal except for their small size. The 
knee-jerks were equal and normal. Kernig's sign was absent. 
There was no enlargement of the peripheral lymph nodes. 

A stool, which was seen, was smooth, dark-colored and 
about the size and shape of the finger. 

Diagnosis. The distention of the abdomen is unquestion- 
ably due to dilatation of the intestines. It is reasonable to 
believe that this dilatation is due primarily to a congenital 
narrowing of the rectum, and that the large intestine only is 
involved. It is possible that there was also some other con- 
genital malformation of the large intestine, but the late 
development of the enlargement of the abdomen makes this 
improbable. It is not quite proper, therefore, to speak of 
this as a Congenital Dilatation of the Colon or Hirsch- 
sprung's Disease, in which the condition is primarily a 
congenital malformation of the whole or a part of the large 



DISEASES OF GASTRO-ENTERIC TRACT. 1 29 

intestine. Whatever the origin, however, the present con- 
dition is now the same as in the typical cases of this type. 

Prognosis. His general condition is better than would be 
expected from the duration of the disease and the size of the 
abdomen. There is no possibility of spontaneous improve- 
ment. Drugs and enemata are merely palliative measures. 
Ulceration of the intestine or marked toxemia from reten- 
tion of the intestinal contents is almost certain to develop 
eventually and to finally cause death. There is a possibility 
of cure by operation. The operation is, however, a serious 
one and more than likely to result fatally. 

Treatment. He can be kept alive and fairly comfortable 
for a considerable time by the combined use of enemata and 
massage of the abdomen. Sooner or later, hov/ever, these 
measures will prove ineffectual and it will be necessary to 
operate upon him or to let him die without operation. The 
operations possible are the making of an artificial anus and 
the removal of the large intestine. The former operation is 
merely palliative, not curative, and, if successful, is a source 
of great discomfort. The removal of the colon is a ver^^ 
serious operation and very likely to prove fatal. If success- 
ful, however, it results in a cure. 



130 CASE HISTORIES IN PEDL4TRICS. 

CASE a7e Mary D., five and one-half months old, had 
always been a perfectly well, breast-fed baby. About 6 a.m., 
September 6, she suddenly began to cry and to put her hands 
on her abdomen. The crying continued for half an hour or 
more. At about this time she had three movements con- 
sisting almost entirely of bright blood. After this she vomited 
two or three times. The character of the vomitus was not 
noticed. Judging from the story, she evidently was somewhat 
collapsed for a short time after the onset of the pain. She 
was seen about 7.30 a.m. by her physician, who examined the 
abdomen but found nothing abnormal. He did not consider 
the condition an important one, although he watched the 
case very carefully afterward. She continued to have seven 
or eight small movements daily, which consisted entirely of 
mucus and blood. The amount of blood, however, had 
steadily diminished. The movements contained no fecal 
matter. A bismuth mixture, which was ordered at the first 
visit, was vomited. There was no more vomiting until the 
noon of the 8th, since when she had vomited almost con- 
stantly. She continued to take the breast well. She had had 
no very sharp attacks of pain, but had slept very little, moan- 
ing most of the time. She did not seem very sick until the 
8th and had noticed things and played a little that afternoon. 
The temperature had been taken morning and evening, but 
had never been over 100° F. The mother thought that she 
felt a bunch in the abdomen the evening of the 7th, but both 
the mother and the doctor failed to find it the next morning. 
She was given two teaspoonfuls of castor oil the morning of 
the 8th, which were vomited, and also several large injections 
of salt and water, which brought away nothing but mucus and 
blood. She was seen in consultation at 9 p.m., September 8, 
sixty-three hours after the onset. 

Physical Examination. She was well developed and nour- 
ished. There was slight pallor. Her face was drawn and 
anxious. She noticed a little. The fontanelle was nearly 
level. The tongue was slightly dry, but not coated. The 
heart and lungs showed nothing abnormal. The liver was 
palpable 3 cm. below the costal border in the nipple line. 
The spleen was not palpable. The level of the abdomen was 





Edward C. Case 31. 



DISEASES OF GASTRO -ENTERIC TRACT. 131 

somewhat below that of the thorax. An indefinite resistance 
was felt in the left lower quadrant. There was no muscular 
spasm, but a little tenderness in this region. The rest of the 
abdomen was negative. Rectal examination showed more 
resistance in the left half of the abdomen than in the right, 
but nothing at all definite. The extremities showed nothing 
abnormal. There was no enlargement of the peripheral 
lymph nodes. The rectal temperature was 100.4° ^'t the 
pulse 180. 

Diagnosis. The diagnosis of Intussusception is so plain 
in this instance that it is hard to understand how it could 
have been mistaken for infectious diarrhea, as was done. 
The sudden onset of severe abdominal pain with partial 
collapse, the vomiting and the passage of bright blood are 
pathognomonic of intussusception and entirely different 
from the slow onset of infectious diarrhea. The further 
course of the disease, with continued abdominal pain and 
numerous stools of mucus and blood without fecal matter, is 
most characteristic. Pain is uncommon, except at the time 
of defecation, in infectious diarrhea at this age, and some of 
the movements always contain fecal matter. The physician 
was undoubtedly misled by the facts that the baby nursed 
well and did not appear very ill. It is, however, not at all 
uncommon for babies with intussusception to take their food 
well almost to the end, and the general condition is often not 
much affected during the first thirty-six hours or so. He was 
also probably further misled by the moderate temperature. 
This, again, is characteristic of intussusception, high fever 
being very unusual. He should have paid more attention to 
the mother's story of a bunch in the abdomen and not have 
trusted so much to his own negative examination, for it often 
happens that the tumor can be felt at one time and not at 
another. The failure to obtain fecal matter from the injec- 
tions should also have suggested intussusception. The castor 
oil was, of course, very bad treatment. If it had been re- 
tained, it would have merely made the intussusception 
tighter. 

The physical examination, as often happens in intussuscep- 
tion, aids but little in the diagnosis. The strained and anxious 



132 CASE HISTORIES IN PEDIATRICS. 

face are suggestive of intussusception, but not inconsistent 
with infectious diarrhea. The indefinite resistance and slight 
tenderness in the left lower quadrant and the increased 
resistance in the left half of the abdomen on rectal examina- 
tion are corroborative of the diagnosis of intussusception, but 
without the history would not be of much importance. 

Prognosis. The prognosis is very grave. It is almost 
certain that during the sixty-three hours since the onset ad- 
hesions have formed so that the intussusception cannot be 
reduced. The circulation has been interfered with so long 
that the gut is almost certainly gangrenous. A resection will 
undoubtedly have to be done. There is not one chance in 
ten for recovery. 

Treatment. The only possible treatment is immediate 
operation. 



DISEASES OF GASTRO-ENTERIC TRACT. 1 33 

CASE 28. Sophie M., nine naonths old, was the child of 
healthy parents. She was bom at full term after a normal 
delivery and had always been well. She had been nursed 
irregularly, but had had no other food except occasionally a 
little zwiebach. 

She woke up from a nap crying, evidently from pain in the 
abdomen, about noon, April 11. She was pale for some time 
after she ceased crying. She had nursed well since then but 
had vomited everything taken, including a number of cathar- 
tics, almost immediately. The vomitus consisted of the food 
taken, with a little water and mucus; it was never greenish or 
brownish. She had had no fecal movement of the bowels, 
although numerous enemata had been given. Once she had 
passed '' a small glassful of clear blood." She had apparently 
not been much feverish and had apparently not had any pain 
since the onset. She had passed very little urine. She was 
seen at noon, April 13, forty-eight hours after the onset. 

Physical Examination. She was well developed and nour- 
ished and a little pale. She was moderately prostrated, but 
her face was not pinched and her eyes were clear. The an- 
terior fontanelle was slightly depressed. The pupils were 
equal and reacted to light. There was no rigidity of the neck 
or neck-sign. The tongue was rather dry, but not red or 
coated. The throat was normal. The heart and lungs were 
normal. There was no rosary. The liver was just palpable. 
The spleen was not palpable. The level of the abdomen was 
a little below that of the thorax. There was no definite 
muscular spasm, but the whole abdomen was held a little 
rigidly, especially in the right lower quadrant. There was 
no tenderness or dullness. Nothing at all definite could be 
made out in the right lower quadrant, but it seemed as if 
there was a little more resistance there than on the other side. 
Rectal examination showed nothing abnormal. The rectum 
was empty. There was no blood on the examining finger. 
The extremities were normal. There was no spasm or pa- 
ralysis; the knee-jerks were equal and normal; there was no 
Kernlg's sign. 

There was no enlargement of the peripheral lymph nodes. 
The rectal temperature was 98.6° F., the pulse 136. 



134 CASE HISTORIES IN PEDIATRICS. 

Diagnosis. The diagnosis in this instance lias between 
acute indigestion, with secondary constipation, and intus- 
susception. The points in favor of intussusception are the 
sudden onset in a breast-fed baby, the continued vomiting, 
the absence of fecal movements, the history of the movement 
of blood, and the slight rigidity and sense of resistance in the 
right lower abdomen. The points against intussusception are 
the character of the vomitus, the slight amount of prostration, 
the absence of an abdominal tumor, the negative rectal exami- 
nation and the low temperature. It may also be argued 
that the history of the passage of '* a small glassful of clear 
blood *' was probably untrue, and that if the baby had passed 
blood once it would certainly have passed it again if the con- 
dition was intussusception. The small amount of urine Is, of 
course, of no importance, merely meaning that very little 
fluid was retained. 

There is no question as to the validity of the objections 
to the diagnosis of intussusception. They are, however, all 
unimportant compared with the almost pathognomonic com- 
bination of the sudden onset of abdominal pain in a breast-fed 
infant, the constant vomiting, the obstipation and the passage 
of blood. These are positive symptoms ; the others are merely 
negative. The absence of fecal vomiting can be explained 
on the ground that the reverse peristalsis Is not very active; 
the absence of frequent movements of blood and mucus, on 
the ground that the constriction is not very tight, and that 
consequently there Is not much congestion or exudation Into 
the bowel, and not much peristalsis set up. The absence of a 
tumor can be explained by the absence of a very tight con- 
striction or of marked swelling, or by the deep location of the 
tumor; the absence of a tumor on rectal examination, by the 
high position of the intussusception; and the low tempera- 
ture by the absence of absorption. 

These signs are so characteristic of Intussusception that it 
is hardly necessary to attempt to rule out other forms of Intes- 
tinal obstruction. Some other form Is, however, a possibility. 
Fortunately, the treatment is the same in any instance. 

Prognosis. The chances for recovery are about even In this 
instance, with a good surgeon, if operation Is done at once. 



DISEASES OF GASTRO-ENTERIC TRACT. 135 

The absence of fecal vomiting and frequent movements, the 
good general condition, the low temperature and the short 
duration of the intussusception are all favorable points. 

Treatment. The only rational treatment for intussuscep- 
tion at any stage is immediate operation as soon as the 
diagnosis is made. Attempts at reduction by inflation of the 
bowel with water or air are in rare instances successful. In 
the vast majority of cases, however, they are unsuccessful, 
they waste time and use up the child's vitality. It is impos- 
sible, moreover, to know at once whether the intussusception 
has been reduced or not by these measures, so that on this 
account still more time is wasted. An early operation is 
usually successful, because at this time the intussusception 
can be easily reduced, while the dangers from opening the 
abdomen are slight in skilled hands. When the operation is 
delayed, the intussusception can usually not be reduced 
because of adhesions, and the bowel is irreparably damaged. 
A resection has to be done or an artificial anus made. Under 
these circumstances the baby almost invariably dies. 



136 CASE HISTORIES IN PEDIATRICS. 

CASE 29. Virginia P., seven months old, had always 
been a perfectly well, breast-fed baby. She began to vomit 
about 6 P.M., November 4. She had a perfectly normal 
movement from the bowels at 7 p.m. When seen by her 
physician, at 7.30 p.m., she was somewhat stupid, but not at 
all collapsed. The physical examination was negative, ex- 
cept for a little more resistance in the left lower abdomen 
than elsewhere. The rectal temperature was normal. She 
was very restless all night, apparently from pain in the 
abdomen. She vomited both of two nursings and also water 
which was given her from time to time. She had seven 
movements, consisting entirely of mucus and blood, during 
the night. Irrigation of the bowels at 9 a.m., November 5, 
brought away nothing but a little blood. She was seen in 
consultation at 12 M., November 5. She had not vomited 
since 5 a.m., although she had taken water freely, and the 
bowels had not moved since the irrigation. 

Physical Examination. She was very fussy, but appar- 
ently not in pain. The mouth was dry, the tongue clean. 
The anterior fontanelle was level. The heart and lungs 
were normal. The lower border of the liver was just pal- 
pable in the nipple line. The spleen was not palpable. The 
level of the abdomen was below that of the thorax. Exam- 
ination of the abdomen was very difficult because of the 
constant crying, but it was finally decided that there was no 
tenderness, spasm or tumor. Rectal examination showed 
nothing abnormal, but the withdrawal of the finger was 
followed by the discharge of a teaspoonful of dark reddish- 
brown water. The extremities showed nothing abnormal. 
The rectal temperature was 100.2° P.; the pulse, 116. 

A positive diagnosis of intussusception was made and 
immediate operation advised. When the surgeon saw her, 
an hour later, she was asleep and a careful examination of 
the abdomen showed nothing abnormal. When she awoke 
she was bright and happy and acted like a normal baby. 
She seemed so well that he thought that the intussusception 
had probably been reduced by the irrigation, or spontaneously 
during the ride to the hospital, and declined to operate 
unless further symptoms developed. 



DISEASES OF GASTRO-ENTERIC TRACT. I37 

She was seen again in consultation at 4 p.m. She had 
taken water freely and had not vomited. She had had no 
food since 5 a.m. The bowels had not moved; neither had 
she passed gas. She had had no pain and had slept a little. 
She was smiling and playing in the nurse's arms and looked 
well, but a little tired. The abdomen was soft, there was no 
tenderness, spasm or tumor. A gush of dark reddish-brown 
water followed the introduction of a suppository. The rectal 
temperature was 102.2° F.; the pulse, 118. 

Diagnosis. There is no doubt that she had an intussus- 
ception. The question is whether it is still present or has 
been reduced. The points in favor of its having been re- 
duced are the cessation of the vomiting and bloody move- 
ments, the absence of pain and tumor, the negative rectal 
examination and the marked improvement in the general 
appearance. The arguments in favor of the intussusception 
being still present are as follows: Reduction by a simple 
irrigation is very unusual. Spontaneous reduction, while it 
may occur, takes place so rarely that it is wiser to take it for 
granted that it never happens. Remissions in the subjec- 
tive symptoms are very common, especially in the first 
thirty-six hours. Pain is seldom present after the onset. 
The tumor cannot be felt if it is situated high up under the 
diaphragm or liver. Rectal examination is always negative 
unless the tumor is low down. There have been no fecal 
movements. The cessation of vomiting is due to the absti- 
nence from food. The temperature is rising in spite of the 
apparent improvement in the subjective symptoms. It may 
be said in rebuttal, however, that there has not yet been 
time for feces to appear and that the rise in temperature is 
due to starvation and fatigue. It is evidently impossible 
to be absolutely sure whether the intussusception has been 
reduced or not. The question must be decided by weighing 
the chances on the two sides. The relative frequency of 
remissions in the subjective symptoms must be balanced 
against that of spontaneous reduction and reduction from 
simple irrigation. The other points can be explained either 
way and are, therefore, of no importance. Remissions are 
infinitely more common than spontaneous reduction or re- 



138 CASE HISTORIES IN PEDIATRICS. 

duction from simple irrigation. The chances are, therefore, 
very much in favor of the persistence of the intussusception, 
so much so that the diagnosis of an Unreduced Intussus- 
ception is justified. 

Prognosis. The prognosis without an operation, if the 
diagnosis is correct, is hopeless. She is in good condition; 
the intussusception occurred less than twenty-four hours ago; 
the symptoms are not very acute. It is probable, there- 
fore, that the intussusception can be reduced and that a 
resection of the bowel will not be necessary. The chances for 
recovery are, therefore, better than even. 

Treatment. She should be operated on immediately. It 
is true that the operation may be found to be unnecessary. 
There is very little risk, however, in an exploratory lapa- 
rotomy, while she is certain to die if not operated upon, if the 
intussusception is still present. 



DISEASES OF GASTRO-ENTERIC TRACT. 1^9 

CASE 30. Mary M., three and a half years old, was in 
the habit of having occasional attacks of vomiting, which 
were usually of short duration. She was a well and vigorous 
but ner\'ous child. She was carefully fed. July i she ate 
an unusually hearty supper of proper food at six o'clock and 
then played very hard and was a good deal excited for about 
half an hour. She went to bed soon after and quickly dropped 
to sleep. She woke up and began to vomit at 9 p.m. The vom- 
iting continued and finally there was much retching without 
vomiting. The vomitus at first consisted of the food taken at 
supper, later of nothing but mucus. She was seen at 1 1 .30 p.m. 

Physical Examination. She was well developed and nour- 
ished and did not look or act ill. Her tongue was nearly 
clean. The level of the abdomen was that of the thorax. 
There was no muscular spasm or tenderness. The rest of 
a careful physical examination showed nothing abnormal. 
The rectal temperature was 98.6° F. 

Diagnosis. The absence of physical signs and the normal 
temperature rule out at once all diseases outside of the diges- 
tive tract. The only diseases of this tract to be considered 
are nervous vomiting, acute indigestion and the onset of 
recurrent vomiting. 

It is impossible to absolutely exclude recurrent vomiting 
at this time, only two and a half hours after the onset, but 
the history of similar attacks in the past, all of short dura- 
tion, makes it very improbable. The differentiation between 
nervous vomiting and acute indigestion is a rather difficult 
and uncertain one, as the line between the two forms is not 
very sharp. The absence of temperature and the practically 
normal condition of the tongue are against indigestion. The 
fact that the vomiting developed after a meal of proper food 
followed by undue exertion and excitement point strongly to 
a nervous disturbance. The over-exertion and excitement 
presumably inhibited digestion, and the undigested food 
acted like a foreign body in the stomach and brought on 
the vomiting by reflex action. The diagnosis is, therefore, 
Nervous Vomiting. 

Prognosis. The prognosis as to life is, of course, good. 
The stomach having been thoroughly emptied, as shown by 



I40 CASE HISTORIES IN PEDIATRICS. 

the character of the last vomitus, the vomiting ought to 
stop in a few hours or less, if nothing is done in the way of 
medication to keep it up. 

Treatment. Quiet and frequent sips of a solution of bi- 
carbonate of soda, fifteen grains to a glass of water, are all 
that is necessary. A mild laxative, such as two teaspoonfuls 
of milk of magnesia, in the morning, to hurry along any undi- 
gested food which may have passed into the intestine is 
advisable. Broth and toast for breakfast, and a rather light 
diet and quiet for the rest of the next day, complete the 
treatment. 



DISEASES OF GASTRO-ENTERIC TRACT. I4I 

CASE 31. Barbara M. was the third child of healthy 
parents. She was born at full term after a hard labor, the 
presentation having been breech. She was normal at birth 
and weighed eight and one-fourth pounds. She had always 
been breast-fed. She lost four ounces during the first week, 
after which she had gained fairly steadily up to four days 
before she was seen, when seven and one-half weeks old, 
when she weighed ten pounds and five ounces. 

She began to vomit when three days old, that is, as soon as 
the milk came in, and had continued to do so ever since. 
The vomiting bore no relation to the time of feeding, oc- 
curring at any and all times. Sometimes she vomited large 
amounts at a time; at others, only a little. Sometimes the 
vomitus was watery, at others it contained curds. It was 
seldom sour and never contained mucus. The duration of 
the nursing made but little difference in the vomiting, as 
much being vomited sometimes after nursing five minutes as 
after fifteen or twenty minutes. Variations in the intervals 
between the nursings had made no difference in the vomiting. 
She had recently been having six feedings at intervals of 
three hours. The vomiting was not explosive, but at times 
the vomitus came up with a spurt, apparently as the result 
of gas in the stomach. She had one or two rather large, 
loose stools daily. These were usually yellow, but some- 
times green, and almost always contained small curds. She 
had no colic, slept well, and did not appear ill. 

Her mother was well, but rather tired, as she had the full 
responsibility of her home and took entire charge of the baby. 
Her husband had also been ill with influenza during the last 
two weeks. 

Physical Examination, She was well developed and nour- 
ished and of good color. Her flesh was hard and firm. The 
anterior fontanelle was level, the posterior was closed. Her 
mouth was healthy and her tongue clean. There was no 
rosary. The heart and lungs were normal. The level of 
the abdomen was a little below that of the thorax. There 
was no visible gastric peristalsis and no tumor was palpable 
in the region of the pylorus. The lower border of the liver 
was palpable 2 cm. below the costal border in the nipple 



142 CASE HISTORIES IN PEDIATRICS. 

line. The spleen was not palpable. The extremities were 
normal. There was no spasm or paralysis. The knee* 
jerks were equal and normal. Kemig's sign was absent. 
There was no enlargement of the peripheral lymph nodes. 

Her stool was large, loose, brownish-yellow, and contained 
a considerable number of soft curds, varying in size from that 
of the head of a pin to that of a BB shot, and a little mucus. 

Diagnosis. The early onset of the vomiting, the lack of 
explosive vomiting, the good state of nutrition, the absence 
of visible gastric peristalsis and pyloric tumor, and the large 
stools rule out stenosis of the pylorus. The absence of ex- 
plosive vomiting and visible gastric peristalsis are sufficient 
to exclude spasm of the pylorus. The difficulty must lie, 
therefore, in either the amount or the composition of the 
breast-milk. The absence of any evidences of disturbed 
digestion in the vomitus and of colic counts strongly against 
any abnormality in the composition of the milk. So also 
does the character of the stools, which are not markedly ab- 
normal. The curds, which are, of course, fatty, and the small 
amount of mucus, may just as well be due to an excessive 
amount of milk as to an abnormal milk. The fact that she 
sometimes vomits as much after nursing five minutes as 
after fifteen minutes does not count against an excessive 
amount of milk as the cause of the vomiting, because the 
amount of milk taken at a nursing varies at different nursings 
and because at least one-half of the amount taken at a nurs- 
ing is taken in the first ^ve minutes, especially if there is a 
large amount of milk and it flows freely. Neither the regular 
gain up to the last few days nor the recent failure to gain 
count against an excessive amount of milk, because whether 
she gains or not depends not upon how much milk she takes 
but upon how much she retains. 

The only way to determine positively whether she is 
getting too much milk or not is to weigh her before and after 
nursing, preferably for twenty-four hours. She was allowed 
to nurse for fifteen minutes and took six ounces. She 
vomited quietly several times during the next ten minutes, 
expelling apparently three ounces of what she had taken. 
This, in connection with the history and physical examina- 



DISEASES OF GASTRO-ENTERIC TRACT. 1 43 

tion, is sufficient to warrant the diagnosis of Indigestion 
FROM AN Excessive Amount of Breast-milk. 

Prognosis. Limitation of the duration of each nursing so 
that the baby will not get more milk than it can handle will 
quickly relieve the symptoms. Moreover, the failure of 
the baby to empty the breasts at the shorter nursings will 
probably soon bring about a diminution in the amount of 
milk. 

Treatment. She should continue to have six feedings 
daily at intervals of three hours. The length of each nurs- 
ing must be limited, so that she will not get enough milk to 
make her vomit. She should, however, be allowed to take 
as much as she can retain without vomiting. It is important 
not to shorten the length of the nursings so much, in the 
endeavor to prevent vomiting, that she will not get enough 
to meet her caloric needs. The length of the nursings can 
be determined, therefore, only by experiment. 



144 CASE HISTORIES IN PEDIATRICS. 

CASE 32. Margaret B. was born at full term after a 
normal labor, was normal at birth and weighed eight and 
one-quarter pounds. 

The breast-milk was very scanty and "looked like al- 
bumin water.'' Nursing was therefore given up after three 
days. She was then fed by an " experienced nurse " who 
gave her one and one-half ounces every two and one-half 
hours of a mixture made as follows: Top 33^ ounces from 
one quart, 33^ ounces; Skimmed milk, 2 ounces; Lime water, 
I ounce; Water, 93^ ounces; Milk sugar, 2 rounded teaspoon- 
fuls. She took this fairly well at first, but after a few days 
took it very poorly. She soon began to vomit very frequently 
and to have many watery, green, irritating stools containing 
many, small, soft curds. The vomiting was not explosive. 
She lost steadily in strength, but not much in weight, weigh- 
ing eight pounds when she was seen in consultation, when 
thirteen days old. She had had no fever. 

Physical Examination. She was fairly developed and 
nourished and of good color. The fontanelles were level. 
Her mouth and throat were normal and her tongue nearly 
clean. The abdomen was level and normal. The cord had 
not come off, but was healthy. The liver was palpable 
3 cm. below the costal border in the nipple line. The spleen 
was not palpable. The extremities were normal. There 
was no spasm or paralysis. The knee-jerks were equal and 
normal. Kernig's sign was absent. There was no enlarge- 
ment of the peripheral lymph nodes. The skin was healthy. 

Diagnosis. The appearance of the vomiting coincident 
with the giving of a new food, the lack of explosive vomit- 
ing and the frequent stools are sufficient to exclude both 
stenosis and spasm of the pylorus. The appearance of 
the symptoms as soon as she was taken off the breast and 
given an artificial food suggests strongly that the food is 
the cause of her trouble. Calculation of the composition of 
the food shows that it contains about 5% of fat, 5.50% of 
sugar and 1.10% of proteids. The percentage of fat is 
higher than should be given to a baby of any age and far 
higher than should be given to a baby only a few days old. 
The percentage of proteids is higher than most babies of 



DISEASES OF GASTRO-ENTERIC TRACT. I45 

this age can tolerate and much higher than should be given 
to a baby onl}^ three days old. One and one-half ounces 
was too much to give to a baby of this age at first and was 
evidently more than she could digest. Many babies of three 
days can take this amount, but less should be given in the 
beginning, the amount being increased later, if necessary. 
It is evident, therefore, that the food is too strong for her 
and that she has been given too much of it. In the absence 
of any other cause for her symptoms they can without hesi- 
tation be attributed to the food. The symptoms are those 
of indigestion and the absence of fever rules out fermentation 
and infection. The diagnosis is, therefore. Indigestion 
FROM Overfeeding with an Artificial Food. 

Prognosis. The prognosis is essentially good. She will 
improve quickly when she is given a proper food in proper 
amounts. It is, however, more difficult and takes longer to 
relieve an acute disturbance of the digestion in a baby of 
this age than in an older baby. It may be some time, 
therefore, before her digestion is normal, and there is a 
remote possibility that so much harm has already been 
done that recovery of the digestive powers cannot take 
place. 

Treatment. The treatment consists entirely in regulation 
of her food. The best food for her is good human milk. 
With a good wet nurse she will be well in a week or less. 
Even with a wet nurse, however, the length of the nursing 
must be very short and it may be necessary in the beginning 
to give water before each nursing in order to dilute the 
breast-milk. While human milk is the best food for this 
baby, it is not absolutely necessary. She will probably do 
well on a weak modified milk given in small amounts. The 
following formula is a suitable one: fats, 2.00%; milk sugar, 
5.00%; protain, 0.75%. 

It will be well to boil the food for ^yq minutes in a single 
boiler in order to make the proteids more digestible. Eight 
feedings of one ounce at two and one-half hour intervals 
should be given. It will probably be necessary to increase 
the amount of food at a feeding within a day or two. The 
strength of the food may be increased later. 



146 CASE HISTORIES IN PEDIATRICS. 

CASE 33. Herbert A. was the third child of healthy 
parents, was born at full term after a normal labor, was 
normal at birth and weighed nine pounds. He had never 
had anything but the breast and had been very well in every 
way until three weeks before he was seen, when four months 
old. He had been having six feedings, at intervals of three 
hours, since he was six weeks old. During the last three 
weeks he had refused to nurse more than five or six minutes, 
although his mother was positive that she had plenty of 
milk. He both raised and passed a great deal of gas, but 
had no colic. He seemed hungry, but the gas apparently 
interfered with his nursing. He did not vomit. He was 
having several stools daily which were of good color, but 
loose, and which contained many, small, soft curds and con- 
siderable mucus. His weight had not changed during this 
time. 

His mother was well, except that she was somewhat con- 
stipated. She was eating freely of a general diet and was, in 
addition, drinking a pint of cornmeal gruel daily. She was 
taking but little exercise and did not get much fresh air. 

Physical Examination. He was well developed and nour- 
ished and of good color. The anterior fontanelle was level. 
His throat and nose were normal and his tongue was clean. 
There was no rosary. The heart and lungs were normal. 
The level of the abdomen was that of the thorax. Nothing 
abnormal was detected in it. The lower border of the liver 
was palpable 2 cm. below the costal border in the nipple 
line. The spleen was not palpable. The extremities were 
normal. There was no spasm or paralysis and no enlarge- 
ment of the peripheral lymph nodes. His rectal temperature 
was normal. He weighed sixteen pounds. 

His stool was loose, golden-yellow, sour and strongly acid. 
It contained many, small, soft curds and a moderate amount 
of mucus. 

Diagnosis. The unwillingness to nurse but a few minutes 
is the most striking symptom. This may be due to an in- 
sufficient supply of milk, in spite of the fact that the mother 
thinks she has plenty. It may be because the milk is so 
rich in fat that it quickly cloys the baby. It may also be 



DISEASES OF GASTRO-ENTERIC TRACT. I47 

the result of indigestion, or may be due to a combination of 
indigestion and too rich a food. The character of the stools 
suggests that the milk contains an excess of fat, while the 
gas shows that there is some disturbance of the digestion. 
He was weighed before and after each nursing for several 
days and took from one to four ounces at a nursing. Milk 
could always be easily expressed from the breasts after he 
had finished nursing, showing that the difficulty was not due 
to an insufiicient supply of milk. An analysis of the breast- 
milk showed that it contained 6% of fat, 7% of sugar and 
1.60% of proteids. It is evident, therefore, that the cause 
of his loss of appetite and other symptoms is the high per- 
centage of fat in the milk. The diagnosis is, therefore, 
Indigestion from an Excess of Fat in the Breast-milk. 

Prognosis. The prognosis is good. It will probably be 
a simple matter to so regulate the mother's diet and life that 
her milk will contain less fat. 

Treatment. It is impossible to diminish the percentage of 
fat in the milk by reducing any special article in the diet. 
A reduction in the amount of the mother's food, as a whole, 
and the cutting out of the cornmeal gruel, will, however, in 
connection with more exercise and fresh air, almost certainly 
quickly bring down the percentage of fat to within normal 
limits. In the meantime it will be well to give one-half 
ounce of water before each nursing in order to dilute the 
milk and in this way reduce the percentage of the fat. 



148 CASE HISTORIES IN PEDIATRICS. 

CASE 34. Ruth L. was the second child of healthy 
parents. She was born at full term after a normal labor, 
was normal at birth, and weighed nearly eleven pounds. 
During the first two and one-half months she was fed partly 
on the breast and partly on modified milk, after which she 
was given modified milk entirely. The milk which was 
used in the preparation of her food was very rich and, as 
she was a hearty baby and her parents were very anxious 
to have her gain rapidly, she was given considerable amounts 
of a strong mixture. She soon became constipated and had 
dry, white stools. After a few weeks she lost her appetite 
and began to vomit. The food was then weakened and her 
appetite returned and she stopped vomiting. The consti- 
pation and peculiar stools continued. When she was four 
months old, however, the amount of cream in the mixture 
was again increased, because she was not gaining rapidly 
enough to satisfy her parents. She seemed all right for two 
days and took her food ravenously. The next morning she 
took two large feedings, but vomited profusely after the 
second one. She became feverish during the day and took 
but little food. In the early afternoon she suddenly had a 
mild convulsion. She was seen in consultation soon after. 
At that time she was out of the convulsion, but was still a 
little twitchy. 

Physical Examination. She was well developed and nour- 
ished, but a little pale. She was generally relaxed, but 
there was a little twitching of the face. The anterior fon- 
tanelle was level. There was no rigidity of the neck or neck- 
sign. The pupils were equal and reacted to light. The ear 
drums showed nothing abnormal. The tongue was moder- 
ately coated. The nose, throat and gums were normal, as 
were the heart and lungs. The level of the abdomen was 
that of the thorax and nothing abnormal was detected in it. 
The liver was just palpable. The spleen was not palpable. 
The extremities were normal. There was no spasm or 
paralysis. The knee-jerks were equal and a little lively. 
Kernig's sign was absent. There was no enlargement of 
the peripheral lymph nodes and no eruption on the skin. 
The rectal temperature was 104° F., the pulse 160, the 



DISEASES OF GASTRO-ENTERIC TRACT. I49 

respiration 40. Her weight was fourteen and one-half 
pounds. 

Diagnosis. The constipation, dry, white stools, loss of 
appetite and vomiting after she was weaned are character- 
istic symptoms of a chronic disturbance of the digestion 
from an excess of fat. This diagnosis is corroborated by 
the facts that she was taking a strong mixture made from 
rich milk and that the symptoms diminished when the food 
was weakened. The sudden onset of vomiting and fever, 
followed by a convulsion, on the third day after extra cream 
was added to the mixture, suggests very strongly that an 
excess of fat in the food was the cause of these symptoms. 
The absence of all evidences of organic disease of the nerv- 
ous system, the normal throat and ear drums, the absence 
of any eruption on the skin, the negative examination of the 
lungs and the normal respiration-pulse ratio practically ex- 
clude all the other diseases which might account for the 
acute symptoms. The diagnosis of Acute Indigestion 
FROM AN Excess of Fat in an Artificial Food is there- 
fore justified. 

Prognosis. The acute symptoms will promptly disap- 
pear as soon as her digestive tract is thoroughly emptied. 
It will, however, require several months of very careful feed- 
ing to overcome her intolerance for fat. 

Treatment. She should be given a tablespoonful of 
castor oil at once and have her colon thoroughly washed out 
with physiological salt solution. She should be given nothing 
but water or a 1.50% barley water, sweetened with sac- 
charin, if necessary, for the next twenty-four hours. She 
may then be given six feedings of five ounces each of the 
following mixture: 

Fat, 0.00% 

Milk sugar, 6.00% 

Proteids, 1.26% 

Starch, 0.75% 

It will probably be many weeks, perhaps months, before 
she can take more than the lowest percentages of fat. Great 
care must be exercised, therefore, in increasing the percent- 
age of fat in her food. 



150 CASE HISTORIES IN PEDIATRICS. 

CASE 35. Mary S., six months old, was the fourth child 
of healthy parents. There had been no known exposure to 
tuberculosis. She was born at full term after a normal labor, 
was normal at birth and weighed five and one-half pounds. 

She was started at first on a weak mixture, copied from 
Dr. Holt^s little book, " The Care and Feeding of Children,'' 
and did very well for a time. The gain in weight was, how- 
ever, very slow, and she did not reach eight pounds until she 
was five months old. She had lost half a pound since then. 
Because of the slow gain in weight, the physician in charge 
rapidly strengthened the formulae, but apparently never 
inquired into the details of the preparation of the food. The 
parents, being even more anxious than the physician to have 
the baby gain in weight, used gravity cream from Jersey 
milk instead of the 10% top milk specified in the book, and 
finally bought thick, pasteurized cream from a dealer. Her 
appetite became very poor. When she came to me, when 
six months old, her mother was attempting to give her eight 
feedings of four ounces at two and one-half hour intervals. 
She seldom took more than twenty ounces in the twenty-four 
hours, however, and this only after much urging, two and a 
half hours often being needed to get in two and one-half 
ounces. She seldom seemed hungry, but, if she did, was 
always satisfied with an ounce. She never vomited unless 
the food was forced too much. She occasionally had a little 
colic but always had a good deal of rumbling in the abdomen 
and passed much gas from the bowels. The bowels were 
usually constipated. The movements were small, crumbly, 
very light yellow, apparently well digested and without much 
odor. She was taking the following mixture: 

Pasteurized rich cream, 5J ounces. 

Whole milk (Jersey), 2 J ounces. 

Lime water, ij ounces. 

Water, i8i ounces. 

Milk sugar, i dessertspoonful. 

Physical Examination. She was small and thin and moder- 
ately pale. She was feeble but intelligent. The veins on the 
scalp were prominent. The anterior fontanelle was 3 cm. in 
diameter and level. The posterior fontanelle was still open. 



DISEASES OF GASTRO-ENTERIC TRACT 151 

There was no craniotabes. The throat was normal; the 
tongue somewhat reddened. There were no teeth. There 
was a marked rosary. The heart and lungs were normal. 
The abdomen was large, but lax. There was no dullness and 
no tumor was made out. The liver was palpable 3 cm. 
below the costal border in the nipple line. The spleen was 
not palpable. The extremities were normal. There was no 
spasm or paralysis; the knee-jerks were equal and normal; 
there was no Kernig's sign. There was no enlargement of the 
peripheral lymph nodes. Her weight was seven and one-half 
pounds. 

Diagnosis. The physical examination justifies nothing more 
than the diagnosis of malnutrition with a slight and unim- 
portant amount of rickets. The cause of the malnutrition 
must be sought in the history. The satiation after taking a 
small amount of food, taken in connection with the lack of 
marked symptoms of indigestion and the slow gain, suggest 
at once too rich a food. The small size, crumbly character 
and light-yellow color of the stools are very characteristic 
and show that they contain fat in the form of soap. The 
story of the substitution of gravity cream from Jersey cows 
for 10% top milk from ordinary cows, and later of rich bottled 
cream for the gravity cream, corroborates, of course, the 
assumption that the food was too rich in fat. It shows also 
how necessary it is for the physician to know exactly how the 
food which he orders is prepared. 

The mixture which the baby was taking, if made of 10% 
cream and whole milk from Holstein or Ayreshire cows, as 
it was supposed to be, would contain about 2.40% of fat, 
3-25% of sugar and 0.90% of proteids, a weak food for the 
age. If made of gravity cream from average milk it would 
have contained about 340% of fat. The modified milk in 
the bottle, however, looked like cream, and when examined 
was found to contain 8.8% of fat. 

The diagnosis is^ therefore, Chronic Indigestion, malnu- 
trition and rickets From an Excess of Fat in the Food. 
The author wishes to call particular attention to the fact 
that in this instance, as in almost all others of disturbed 
nutrition or digestion from an excess of fat in the food, the 



152 CASE HISTORIES IN PEDIATRICS. 

excess was a gross one, the amount being far beyond the 
normal top limit of 4%. 

Prognosis. The prognosis is good on a reasonable diet. 
The gain in weight will probably be slow, and it will be a 
long time before the baby will be able to take as high a per- 
centage of fat as the average baby, as it is always difficult to 
develop the ability to digest fat again when it has once been 
seriously impaired. 

Treatment. The treatment is entirely by regulation of the 
diet. Human milk would be the best food and would almost 
certainly agree, in spite of its comparatively high fat content. 
Next to this is some modification of cow's milk. The milk 
should come from Ayreshire or Holstein cows. The per- 
centage of fat should be low because of the impaired power of 
digestion of fat. The caloric value can be made up by higher 
percentages of sugar and proteids. There is no indication 
for the addition of an alkali. Three ounces is as much as she 
ought to be expected to take at a feeding. Eight feedings, 
at two and a half hour intervals, will be sufficient. The 
following formula is a suitable one: 

Fat, 2.50% 

Sugar, 5.00% 

Proteids, 1-25% 

This gives 100 calories and 2.6 grams of proteid per kilo. 

The baby should not be fed at other than the regular inter- 
vals and, if she does not take the food willingly, the attempt 
to make her take it should not be prolonged over half an 
hour. If the constipation persists it may be treated by 
enemata of suds or sweet oil, or by suppositories of soap, 
glycerin or gluten, but not by sweet oil by the mouth. 



DISEASES OF GASTRO-ENTERIC TRACT. 1 53 

CASE 36. Eleanor S., five and one-half years old, was 
the only child of healthy parents. There had been no deaths 
or miscarriages and no known exposure to tuberculosis. She 
was perfectly well until she was one and one-half years old, 
since when she had had repeated attacks of indigestion. She 
had, however, been better than usual during the year preced- 
ing the present attack, which had begun two months before. 
She had been having three or four undigested stools daily 
and had occasionally vomited. Her diet had been cut down 
without much effect on the symptoms. Her appetite was 
poor, she had a little fever most of the time, had lost at least 
five pounds in weight and much strength and color. 

Physical Examination. She was small, thin and pale, but 
unusually intelligent. Her tongue was clean and her throat 
normal. The heart and lungs were normal. The abdomen 
was much enlarged, the circumference of the chest at the 
nipples being 47 cm., while the greatest circumference of 
the abdomen was 52^ cm., and that at the navel, 48 cm. It 
was everywhere tympanitic. No masses were felt and there 
were no evidences of fluid. The liver and spleen were not 
palpable. The kidneys were normal. There was no spasm 
or paralysis. The knee-jerks were equal and normal. The 
peripheral lymph nodes were not palpable. The rectal tem- 
perature was 100° F. Her weight, with her clothes, was 27 
pounds (the average is 39.6 pounds), and her height, without 
her shoes, 36! inches (the average is 41.3 inches). 

Diagnosis. The diagnosis of Indigestion is self-evident. 
This diagnosis is, however, not sufiicient. It is necessary, 
in order to treat the condition satisfactorily, to find out 
which of the food elements she can digest and which she 
cannot. Her mother was told, therefore, to feed her as 
she had been doing, to keep a careful record of exactly 
what she ate and to bring in her stools and urine for ex- 
amination. She took 30 grams of fat, loo grams of car- 
bohydrates and 24 grams of proteid in the twenty-four 
hours, having a caloric value of 787. She had three stools 
which were soft, cream-colored, smooth, except for the 
presence of vegetable chafi, foul in odor and alkaline in 
reaction. Microscopically they contained a large amount 



154 CASE HISTORIES IN PEDIATRICS. 

of soap and fatty acid splinters, but no starch, muscle fibres 
or mucus. The urine contained no albumin or sugar, but 
showed a very marked positive reaction with Millon's re- 
agent. The soap and fatty acid crystals in the stools show 
that she is unable to take care of even 30 grams of fat in 
the twenty-four hours, which is far less than the average fat 
capacity at this age, while the foul odor of the stools and the 
positive reaction with Millon's reagent show that there is 
putrefaction of the proteids. The final diagnosis is, there- 
fore, CHRONIC INDIGESTION WITH MARICED INTOLERANCE OF 

EAT and diminished tolerance of proteids. 

Prognosis. She will probably eventually recover. It will, 
however, take a number of years of the most careful treat- 
ment to bring this about. She will, moreover, almost cer- 
tainly always be small. 

Treatment. The treatment consists in adapting her diet 
to her digestive capacity. The fats must be eliminated as 
far as possible and the proteids reduced to approximately 
the amount necessary to cover her proteid need. Milk 
proteids are the best, because the products of the decomposi- 
tion of the proteids of milk are somewhat less toxic than those 
of the proteids of meat and eggs. The lactic acid forming 
organisms have an inhibitory action on the proteolytic 
bacteria. They should be given, therefore, to diminish the 
decomposition of the proteids. They are best administered 
in the form of buttermilk. A quart of buttermilk contains 
35 grams of milk proteids, which is equal to about 3 grams 
of proteid per kilo of her weight, an amount amply sufficient 
to cover her proteid need. It contains about 5 grams of fat 
and provides 360 calories. The average caloric need at her 
age is 1200. She is so small, however, that she does not re- 
quire as many calories as the average child of her age. Her 
caloric need, reckoned at 70 calories per kilo, is only 800. 
It will be well, however, on account of her small size and 
emaciation, to give her, if possible, 1000 calories daily. The 
additional calories must be given in the form of carbohy- 
drates. One ounce of crackers, two slices of bread, a potato 
the size of an egg, four tablespoonfuls of cereal, four tea- 
spoonfuls of sugar and the juice of an orange will, for example, 



DISEASES OF G ASTRO-ENTERIC TRACT. 



155 



provide 620 calories and bring the total number of calories 
up to 980. (See Table of Food Values, page 449.) They 
will add only 4 grams of fat and but little proteid. It is, 
of course, not necessary to give the same carbohydrate 
foods every day; in fact, she will tire of her diet much less 
quickly, if they are varied from day to day. The following 
carbohydrate foods are suitable for her: 



White bread. 
French bread. 
Whole wheat bread 
Plain crackers. 
Educators. 
Oatmeal. 
Cream of wheat. 
Wheat germ. 
Germea. 



Ralston. 

Farina. 

Rice. 

Hominy. 

Cracked wheat. 

Shredded wheat biscuit. 

Baked potato. 

Mashed potato. 

Boiled potato. 



Stewed potato. 
Plain macaroni. 
Plain spaghetti. 
Tapioca. 
Sago. 

Orange juice. 
Grapes. 
Sugar. 



It will probably be possible, a little later, when the proteid 
putrefaction has been overcome by the lactic acid bacilli and 
the excess of carbohydrates, to add broths, clear soups, white 
of egg and lean meat to her diet. It will also be well, in order 
to increase the variety of her food, to substitute skimmed 
milk for a part of the buttermilk. Still later, strained green 
vegetables and a little fruit may also be added. A reasonable 
diet for her will then be as follows : 



Buttermilk. 
Skimmed milk. 
Mutton broth. 
Chicken broth. 
Bouillon. 
White of egg. 
Lamb chop. 
Mutton chop. 
Beef steak. 
Roast lamb. 
Roast mutton. 
Boiled mutton. 
Roast beef. 
Roast chicken. 
Boiled chicken. 
Broiled chicken. 
White bread. 
French bread. 



Whole wheat bread. 
Plain crackers. 
Educators. 
Milk toast. 
Oatmeal. 
Cream of wheat. 
Wheat germ. 
Germea. 
Ralston. 
Farina. 
Rice. 
Hominy. 
Cracked wheat. 
Shredded wheat bis- 
cuit. 
Baked potato. 
Mashed potato. 
Boiled potato. 



Stewed potato. 

Plain macaroni. 

Plain spaghetti. 

Strained string beans. 

Strained spinach. 

Strained peas. 

Asparagus. 

Stewed celery. 

Baked apples. 

Stewed prune pulp. 

Grapes. 

Orange juice. 

Junket. 

Corn starch pudding. 

Tapioca. 

Sago. 

Plain blanc mange. 



156 CASE HISTORIES IN PEDIATRICS. 

There is little to be hoped from drugs in this instance. 
There is no indication for hydrochloric acid and pepsin, 
because the gastric digestion is but little impaired. Pan- 
creatin will be destroyed in the stomach and can, therefore, 
do no good. It will be well, however, to give her five drops 
of the tincture of nux vomica, in a teaspoonful or more of 
water, three times a day, before meals, to stimulate her 
appetite. All forms of oil are, of course, contraindicated. 



DISEASES OF GASTRO-ENTERIC TRACT. 1 57 

CASE 37. Frances R. was the first child of healthy 
parents. She was delivered by high forceps at full term, 
was normal at birth, and weighed eight and one-quarter 
pounds. She was nursed entirely for two and one-half 
months and weighed then twelve and one-half pounds, a 
gain of four and one-quarter pounds, or more than six ounces 
a week. She had had, however, considerable colic, had 
vomited occasionally and had been somewhat constipated. 
Her mother then menstruated, but she showed no more 
evidences of indigestion than before. She was, nevertheless, 
very foolishly weaned, on the advice of her physician, be- 
cause of her mother's menstruation and the colic. 

The same physician prescribed a milk mixture containing 
both milk sugar and Mellin's Food. She immediately be- 
gan to have much gas and far more colic, and to vomit more. 
The vomitus was usually watery and very sour. She also 
began to have ^yq or six loose stools daily, which were some- 
times green and sometimes brownish-yellow. They had a 
sour odor and irritated the buttocks. She made no gain in 
weight and after two weeks her parents very sensibly em- 
ployed another physician. She was seen in consultation the 
next day. 

Physical Examination. She was well developed and nour- 
ished and of fair color. The anterior fontanelle was level 
and her tongue was clean. There was no rosary. The heart 
and lungs were normal. The abdomen was somewhat dis- 
tended, but was otherwise normal. The lower border of 
the liver was palpable 3 cm. below the costal border in the 
nipple line. The spleen was not palpable. The extremities 
were normal. There was no spasm or paralysis. The knee- 
jerks were equal and normal. Kernig's sign was absent. 
There was no enlargement of the peripheral lymph nodes. 
The buttocks were slightly excoriated. The rectal tempera- 
ture was normal. 

Her stools were loose, greenish-brown in color, sour, acid in 
reaction, and contained a very few, small, soft curds and a 
little mucus. They showed no excess of fat microscopically. 

Diagnosis. The gas and colic, the sour vomitus, and the 
loose, sour, acid, irritating stools, are so characteristic of 



158 CASE HISTORIES IN PEDIATRICS. 

Indigestion Due to an Excess of Sugar that there can be 
no doubt as to the correctness of this diagnosis. The fact 
that the stools are greenish-brown instead of green is ex- 
plained by the MeUin's Food in the mixture. The diag- 
nosis is further substantiated by the composition of the food, 
which, by calculation, contams S'33% ^^ ^^t, 15% of sugar 
and 1.10% of proteids. About one-half of the sugar is milk 
sugar, while the other one-half is made up of a combination 
of dextrins and maltose furnished by the MeUin^s Food. 
It is impossible to know, when there are so many forms of 
sugar in the mixture, whether the indigestion is due to some 
one of them or the excess of sugar as a whole. 

Prognosis. The prognosis is good. Recovery will prob- 
ably be prompt when the percentage of sugar in the mixture 
is reduced. 

Treatment. The ideal treatment would be to put the 
baby back on its mother's milk, from which it should not 
have been weaned. This has unfortunately entirely dis- 
appeared, however, and, in spite of the fact that the se- 
cretion of breast-milk can sometimes be reestablished in a 
remarkable way, the chances of getting it back are so slight 
that they do not justify the effort. The best substitute 
for its mother's milk would be a wet nurse. A wet nurse is 
hardly necessary in this instance, however, as the baby will 
almost certainly recover quickly on a milk mixture low in 
sugar. As it is impossible to know from the history and 
symptoms whether the disturbance is due to milk sugar, 
to the combination of dextrins and maltose in the MeUin's 
Food, or simply to an excess of sugar, it will be wise to use 
milk sugar in the mixture, this being the most suitable form 
of sugar for an infant. The following mixture is a rational 
one for her: 

Fat, 3.00% 

Milk sugar 4.00% 

Proteids, 1.00% 

She may be given seven feedings of four ounces at intervals 
of three hours. 



DISEASES OF GASTRO-ENTERIC TRACT. ISQ 

CASE ^S. Charles I. was the first child of healthy 
parents. He was delivered by forceps at full term, was 
normal at birth, and weighed seven and three-quarters 
pounds. No attempt w^as made to put him to the breast, 
because his mother's nipples were inverted. He was given 
modified milk prepared at the Walker- Gordon Laboratory 
from the beginning. The mixtures had always been weak 
and had always been made up with the Walker- Gordon 
^^ maltose. '' This preparation contains about 57% of mal- 
tose and 31% of dextrins. He was taking, when seen, 
seven feedings of four and one-quarter ounces of a mixture 
containing 1.75% of fat, 4.50% of "maltose" and 1% of 
proteids. He was not satisfied with this food. He had 
suffered a great deal from colic during the first three months 
and still had considerable gas. He had never vomited. 
His bowels had always been loose. Recently he had been 
having six or eight stools daily. His gain in weight had 
always been slow and he had not gained at all in the last 
five weeks. He was seen in consultation when four and 
one-half months old. 

Physical Examination. He was long and thin, but of 
good color. He was bright, happy and strong. The fon- 
tanelle was a little depressed. His mouth was healthy and 
his tongue clean. There was a very slight rosary. The 
heart and lungs were normal. The level of the abdomen 
was that of the thorax and nothing abnormal was detected 
in it. The liver was palpable i cm. below the costal border 
in the nipple line. The spleen was not palpable. The ex- 
tremities were normal. There was no spasm or paralysis. 
The knee-jerks were equal and normal. There was no en- 
largement of the peripheral lymph nodes. The rectal 
temperature was normal. He weighed nine pounds and six 
ounces. 

His stools were small, loose and smooth, brown and alka- 
line in reaction. Microscopically they contained a very 
small amount of soap. 

Diagnosis. The frequent, loose, brown stools are char- 
acteristic of an excess of maltose in the food. The alkalinity 
of the stools may be in part due to the relatively high per- 



l6o CASE HISTORIES IN PEDIATRICS. 

centage of proteids in proportion to that of the fat in the 
food, but is probably caused chiefly by the large amount of 
alkaline salts in the maltose, which entirely overbalances 
the tendency of the maltose to cause acid stools. The colic 
and gas are also almost certainly due to the maltose in the 
food. The diagnosis of Indigestion from an Excess of 
Maltose is very obvious. He is also suffering from a 
moderate amount of Malnutrition. This disturbance of 
nutrition may be in part due to the diarrhea caused by the 
maltose, but is probably mainly the result of an Insuffi- 
cient Amount of Food. This assumption is justified by the 
fact that his present food gives him only about eighty cal- 
ories per kilo. The rosary shows that he has rickets. This 
being the only sign of rickets present, however, it is of little 
or no importance. 

Prognosis. In spite of the indigestion and disturbance of 
nutrition he is strong and vigorous. He can, therefore, be 
confidently expected to improve rapidly when he is given a 
sufficient amount of a proper food. 

Treatment. The best food for him would be human milk. 
His condition is so good, however, that it is not necessary 
to get a wet nurse for him. He should be given a stronger 
modified milk with the sugar in the form of milk sugar. A 
higher percentage of carbohydrates can be safely given, if 
part of it is in the form of starch. The following mixture is 
a suitable one : 

Fat, 2.50% 

Milk sugar, 6.00% 

Proteids, i-75% 

Starch, 1.00% 

He may be given seven feedings of four and one-half 
ounces of this mixture, as at present. This will give him 
about 125 calories per kilo, which wiU amply cover his caloric 
needs. 



DISEASES OF GASTRO-ENTERIC TRACT. l6l 

CASE 39. Sherman L. was the first child of healthy 
parents. He was born at full term after a normal labor, 
was normal at birth, and weighed six and one-half pounds. 
He was nursed for five months and was then weaned because 
he was not gaining and had undigested stools. He did 
better on artificial food, but continued to be under weight. 
Except for an occasional slight attack of diarrhea, he had 
been well. 

Two months before he was seen, when three years old, he 
began to have from two to four large, loose, stools daily. 
His appetite remained very good, however, and he was not 
troubled by flatulence or vomiting. He did not seem ill. 
His diet had always contained a large amount of starchy 
foods and since the onset of the diarrhea the proportion of 
such foods had been increased. His diet, when he was seen, 
was made up of a quart of milk daily, broths with rice, beef 
juice, eggs, stale bread and zwiebach. He was having four 
meals daily, but was so unsatisfied with them that he was 
given zwiebach freely between them. In fact, he had been 
eating as many as eighteen pieces of zwiebach daily. 

Physical Examination. He was well developed and nour- 
ished and of good color. His tongue was clean, his teeth in 
good condition and his mouth and throat normal. The 
heart and lungs were normal. The abdomen was a little 
full, but otherwise normal. The liver and spleen were not 
palpable. The extremities were normal. There was no 
spasm or paralysis. The knee-jerks were equal and normal. 
There was no enlargement of the peripheral lymph nodes. 

His stool was large, loose, a little frothy, yellow, sour, 
acid, and contained a large amount of starch, but no fat in 
any form. 

Diagnosis. The large amount of starch in his diet at 
once arouses the suspicion that this is probably the cause of 
the frequent and loose stools. The findings in the stool 
prove that this suspicion is well founded and that the diag- 
nosis is Indigestion from an Excess of Starch. 

Prognosis. The prognosis is very good. He will begin 
to improve at once when the starch in his diet is cut down, 
and will be well in a few weeks. 



l62 



CASE HISTORIES IN PEDIATRICS. 



Treatment. The treatment consists, of course, in cutting 
down the starch in his diet and giving him more fat and 
proteids. It is not necessary to ehminate starch entirely, 
but only to diminish it to the point where he can tolerate it. 
This point can be told fairly well by observing his symp- 
toms, but far better by examining his stools microscopically. 
It will be wiser not to give him green vegetables or fruit 
until his stools have become normal. He should have four 
meals daily and should not be given anything to eat be- 
tween his meals. A reasonable diet for him will be: 
Butter Pettijohn 

Stale bread Ralston 

Toast bread Farina 

Whole wheat bread Rice 



MHk 
Broth 
Beef juice 
Soft boiled eggs 
Lamb chop 
Mutton chop 
Roast chicken 
Boiled chicken 
Beef steak 



Milk toast 
Zwiebach 
Plain crackers 
Oatmeal 
Cream of Wheat 



Baked potato 
Plain macaroni 
Junket 

Baked custard 
Plain blanc mange 



DISEASES OF GASTRO-ENTERIC TRACT. 163 

CASE 40. Russell H., three years old, was born at full 
term, was normal at birth and weighed ten and one-half 
pounds. His parents were healthy and there had been no 
known exposure to tuberculosis. He was breast-fed and when 
six months old weighed thirty pounds. His mother began to 
give him other food very early and for the past year his diet 
had been very unsuitable for a child of his age. He was given 
very little meat or vegetables, but many sweets and bananas. 
His appetite had been poor for nearly six months, during 
which time he had lost eight pounds. Recently it had been 
necessary to force him to eat. He had not vomited, but was 
inclined to constipation. The movements were at times 
greenish; at others, clay-colored. They never contained 
mucus. He had been very forward up to the past six months. 
Since then he had grown steadily weaker, so much so that he 
had fallen down several times on a short walk two days be- 
fore. His mother said that he " seemed tired all the time," 
and that he did not '' romp and play " as formerly. He was 
irritable and picked his nose a great deal. His mother, sus- 
pecting worms, had given him ''True's Elixir " several times, 
but had never obtained any worms. He had had no serious 
illnesses, merely an occasional cold. 

Physical Examination. He was fairly developed and nour- 
ished. His color was fair. There was no jaundice. His 
tongue was moist and moderately coated; the papillae were 
unusually distinct. There was a tendency to keep his mouth 
open and a small amount of adenoids was felt with the 
finger. The tonsils were not enlarged. The heart and lungs 
were normal. The liver and spleen were not palpable. The 
abdomen was moderately enlarged, but lax. There were no 
indications of fluid and no masses were felt. The extremities 
were normal. There was no spasm or paralysis; the knee- 
jerks were equal and normal. There was no enlargement of 
the peripheral lymph nodes. He weighed thirty-seven pounds. 

The urine was pale, acid in reaction and contained neither 
albumin nor sugar. 

Diagnosis. Loss of appetite, progressive failure in weight 
and strength and irritability are symptoms common to so 
many diseases that they are of no special importance in diag- 



164 CASE mSTORIES IN PEDIATRICS. 

nosis. The history of over-feeding with sweets and bananas 
points very strongly to indigestion from injudicious feeding 
with carbohydrates, especially sugars, as the cause of his 
symptoms. The clay-colored stools show that there is also 
an intolerance for fat, probably secondary to the disturbance 
caused by the carbohydrates. Enlargement of the abdomen 
and a moist tongue with prominent papillae are very char- 
acteristic manifestations in chronic disturbance of the di- 
gestion of this nature. The only other possibility worthy 
of serious consideration is chronic diffuse tuberculosis. 
While this might account for the general symptoms, in- 
digestion does so equally well. There are no local mani- 
festations of tuberculosis, while the enlarged abdomen and 
the peculiar condition of the tongue are characteristic of 
indigestion of this type. Tuberculosis can, therefore, be 
ruled out and a positive diagnosis of Chronic Indigestion 
FROM AN Excess of Carbohydrates made. 

The mother's diagnosis of ^' worms '* would not be worth 
mentioning if this diagnosis was not made so often, not only 
by mothers and grandmothers, but also by doctors who 
ought to know better, when children lose their appetite and 
are irritable, especially if they pick their noses. None of 
these symptoms are characteristic of the presence of worms. 
Picking the nose is merely a manifestation of nervousness; 
irritability and anorexia of a host of conditions. In fact, the 
author's experience leads him to believe that when children 
are thought to have w^orms they are almost invariably suf- 
fering from some other trouble and that when worms are 
found the children usually seem perfectly well. The absence 
of worms in the stools after the administration of an anthel- 
mintic rules them out in this instance. 

Prognosis. There is no danger to life except from inter- 
current disease, to which the child is predisposed by his 
weakened condition. Recovery is likely to be slow at best 
and to be interrupted by relapses. How rapidly he improves 
depends largely on how carefully the mother follows direc- 
tions. It will be two or three months, at any rate, before he 
is well. He is very likely to have a recurrence of his trouble 
unless he is very carefully fed and watched over for several 



DISEASES OF GASTRO -ENTERIC TRACT 



165 



Treatment. The treatment is mainly dietetic. Sweets 
and fats must be entirely excluded from this diet for a time, 
and starches given only in moderation. The following 
diet is a reasonable one for him. 



Skimmed milk. 
Mutton broth. 
Chicken broth. 
Beef broth. 
Beef juice. 
White of egg. 
Lamb chop. 
Mutton chop. 
Roast chicken. 
Boiled chicken. 
Roast lamb. 
Roast mutton. 
Beef steak. 
Roast beef. 
Scraped beef. 



Boiled fish. 
Stale bread. 
Toast bread. 
Whole wheat bread. 
Milk toast. 
Zwiebach. 
Plain crackers. 
Educators. 
Barley jelly. 
Oatmeal jelly. 
Petti John. 
Cream of wheat. 
Wheat germ. 
Farina. 
Rice. 



Baked potato. 
Mashed potato. 
Plain macaroni. 
Peas. 

String beans. 
Spinach. 
Asparagus. 
Summer squash. 
Lettuce. 
Stewed celery. 
Orange juice. 
Junket. 
Blanc mange. 
Tapioca. 



After he begins to improve, the amount of the starches may 
be increased, then yolk of egg and a little butter added, and 
finally whole milk substituted for skimmed milk. It is wise, 
however, to be very cautious about increasing the diet. 
Sugar, or foods containing sugar, must not be given for many 
months; saccharin may be used in its place if necessary. 
Hygienic treatment is also of importance. It is especially 
necessary to avoid fatigue and chilling. He should take a 
rest of one or two hours at noon, get up late and go to bed 
early, and be warmly dressed, especially about the abdomen. 

Tincture of nux vomica seems to help this condition. 
The dose for this boy is three drops, three times a day, before 
meals, given in a little water, not in syrups or mixtures. 
He may not like it, but he can be made to take it. Phosphate 
of soda and cascara sagrada are the best laxatives, if any 
are needed. 



1 66 CASE HISTORIES IN PEDIATRICS. 

CASE 45. Ernest B. was the third child of healthy 
parents. He was born at full term, October 1 1 , after a normal 
labor, was normal at birth and weighed eleven and one- 
quarter pounds. His mother had an abundance of milk and 
was better in health than she had ever been. He nursed well 
and did not vomit, but cried a great deal and had many loose, 
green stools, containing fine curds and a little mucus. The 
milk was analyzed October 23 and found to contain 2.75% of 
fat, 5.05% of sugar and 3.94% of proteids. The attending 
physician got the mother out of bed when the baby was two 
weeks old and out of doors when he was four weeks old with 
the hope of reducing the proteids in the milk by exercise. 
The baby, nevertheless, continued to cry almost constantly 
and to have eight or ten movements, of the same character, 
daily. He did not vomit, however, and gained steadily in 
weight. When seen November 29, at the age of seven weeks, 
he weighed thirteen pounds and ten ounces, having gained ten 
ounces in the last week. He was getting seven feedings in the 
twenty-four hours, the intervals between the nursings being 
three hours during the day and four and one-half hours at 
night. He had been weighed before and after nursing for 
several days and found to get about twenty-eight ounces of 
milk during the twenty-four hours. His mother felt un- 
usually well in every way and was not worried or nervous. 
She did not take care of the baby and was, therefore, not dis- 
turbed by the crying. She was taking very little exercise, 
however, and was not out of doors more than one or two 
hours a day. Another analysis of the milk was made the day 
that he was seen and it then contained 2.65% of fat, 5.95% of 
sugar and 2.93% of proteids. 

Physical Examination. He was well developed and nour- 
ished and of good color. The posterior fontanelle was closed. 
There was no rosary. The heart, lungs and abdomen were 
normal. The lower border of the liver was palpable two cm. 
below the costal border in the nipple line. The spleen was not 
palpable. The extremities and external genitals were nor- 
mal. There was no irritation of the buttocks. There was no 
spasm or paralysis. The knee-jerks were equal and normal. 
There was no enlargement of the peripheral lymph nodes. 



DISEASES OE GASTRO-ENTERIC TRACT. 167 

The stools were small, very loose, green, slightly acid in 
reaction and contained a few small, soft curds and a little 
mucus, but were not frothy. 

Diagnosis. He has, without question, a disturbance of 
the digestion. This must be connected in some way with 
the breast-milk. It cannot be due to an excess of milk, be- 
cause twenty-eight ounces of this milk will not give him 
more than 90 calories per kilo. It must be due, therefore, 
to something in the composition of the milk. It cannot be 
due to the fat, because the percentage of fat is somewhat low 
and the stools show no evidences of fat indigestion beyond a 
few small curds. It certainly is not caused by the sugar, 
because the percentage of sugar in the milk is within the 
normal limits, there is no irritation of the buttocks, the 
acidity of the stools is slight and they are not frothy. It is 
evident, by exclusion, therefore, that it must be due to the 
proteids. This conclusion is corroborated by the high per- 
centage of the proteids and by the symptoms, which are 
those characteristic of an excess of proteids in breast-milk. 
The diagnosis is, therefore, Indigestion from an Excess oe 
Proteids in the Breast-Milk. 

Prognosis. The percentage of proteids in the milk has 
dropped from 3.94 to 2.93 since the mother has been out of 
bed, although she has taken but little exercise and has been 
out of doors but little. She is well and is not nervous or 
worried. The excessive amount of proteids is undoubtedly 
due, therefore, to lack of exercise. It is possible for her to 
get it. If she does, the percentage of proteids will rapidly 
fall to normal and the symptoms of indigestion cease. 

Treatment. Exercise diminishes the amount of proteids 
in the milk, if they are excessive. If the exercise is carried 
to the point of fatigue, however, they increase again. The 
treatment in this instance consists, therefore, entirely in 
regulation of the mother's exercise. She must exercise out 
of doors until she is comfortably tired, but not fatigued. 
Walking is the best form of exercise for her at this time of 
year. There is no reason why she should not eat a general 
diet and lead an ordinary life in every way. 



1 68 CASE HISTORIES IN PEDIATRICS. 

CASE 42. John B., the fifth child of healthy parents, was 
born at full term after a normal labor. He was normal at 
birth and weighed eight and three-fourths pounds. He was 
not nursed, but was started at once on a modified milk con- 
taining 2.50% of fat, 5.50% of sugar, 0.80% of proteids, with 
lime water 5% of the total quantity. He did not thrive on 
this and was soon put on a mixture containing 340% of fat, 
6.50% of sugar, 1.50% of proteids and 0.75% of starch. The 
lime water was still 5% of the total quantity. He took this 
well, but was not satisfied. He did not vomit, but was 
constipated. The movements contained many large, tough 
curds, but were of good color and did not contain mucus. 
When four weeks old he was changed to a pancreatized mix- 
ture containing 3% of fat, 3.50% of sugar and 2% of proteids. 
When seen, at five months, he was still taking this mixture, 
getting six or seven feedings of four ounces at three-hour 
intervals. Seven feedings of four ounces of this mixture 
gives 106 calories and 4.2 grams of proteid per kilo. He was 
also taking two teaspoonfuls of olive oil daily. He did not 
vomit, but had considerable gas. The bowels did not move 
without laxatives. The movements were light green or yellow 
in color and always contained large, hard curds, but no 
mucus. He did not gain in weight. 

Physical Examination. He was bright and happy. He 
was small and thin and his color was fair. The fontanelle 
was 3 cm. in diameter and level. The bones of the skull did 
not overlap. The tongue was slightly reddened; the mouth 
and throat were otherwise normal. There was no rosary. 
The heart and lungs were normal. The level of the abdomen 
was slightly below that of the thorax; nothing abnormal was 
detected in it. The liver was palpable I cm. below the costal 
border in the nipple line. The spleen was not palpable. The 
extremities were normal. There was no spasm or paralysis; 
the knee-jerks were equal and normal ; there was no Kernig's 
sign. There was no enlargement of the peripheral lymph 
nodes. His weight was eight pounds and thirteen ounces. 

Diagnosis. The physical examination justifies nothing 
more than a diagnosis of malnutrition. The slight reddening 
of the tongue is probably merely the result of local irritation 



DISEASES OF GASTRO-ENTERIC TRACT. 169 

from the nipple, but may be a manifestation of indigestion. 
The large, hard curds in the movements show that the casein 
is not properly digested. The amount of proteid in the food, 
4.2 grams of proteid per kilo, is, moreover, excessive. There 
is nothing about the movements to shov/ any disturbance of 
the digestion of either fat or sugar. The failure to gain and 
the constipation suggest an insufficient supply of food. One 
hundred and six calories per kilo ought, theoretically, to be 
enough, but probably is not, as the caloric needs presumably 
depend somewhat on the age as well as on the weight. That 
is, a well baby of five months needs more calories per kilo 
than a fat baby of the same weight of one month. The 
diagnosis of malnutrition from an insufficient supply of food, 
and mild Indigestion from an Excess of Proteids in 
Cow^s Milk is, therefore, justified. 

Prognosis. The cheerfulness and the absence of marked 
signs of wasting show that the disturbance of nutrition is 
not a severe one. The disturbance of digestion is only in that 
of the proteids. These can be easily considerably lowered 
and still cover the proteid needs, while the fat and sugar can 
be increased to cover the caloric needs. The prognosis is, 
therefore, good. 

Treatment. The treatment is, of course, entirely by regu- 
lation of the diet and not by the administration of drugs. 
Human milk, as in all the chronic disturbances of digestion 
or of malnutrition in infancy, is the best food. In this 
instance, however, it does not seem a necessity. 

The caloric value of the food can best be increased by rais- 
ing the percentage of sugar to 7, as the sugar is at present 
altogether too low. There is also no objection to giving five 
ounces at a feeding. After this is done it w^ill not be necessary 
to increase the percentage of the fat, which is now a reason- 
able one. The percentage of proteids should be lowered 
somewhat, as the excessive amount is throwing unnecessary 
work on the eliminative organs, and they are not needed to 
keep up the calroic value of the food, which can be supplied 
by the fat and sugar, which are digested. A considerable 
proportion of the proteids should be given in the form of 
whey proteids, as the large curds show that it is the casein 



lyo CASE HISTORIES IN PEDIATRICS. 

which is not digested. An alkali is not indicated, as there is 
no vomiting. The following formula meets these indications: 

Fat, 3 -00% 

Sugar, 7 -00% 

Whey proteids, 0.75% 

Casein, 0.25% 

Seven feedings of five ounces of this mixture give 159 
calories and 2.6 grams of proteid per kilo. 

Another method of rendering the casein more digestible is 
by the addition of starch to the food, which by its mechanical 
action prevents the formation of large curds; 0.75% of starch 
has as much effect as larger amounts. There is no objection 
to giving this amount of starch because, while it is true that 
the amylolytic function is only partially developed at this 
age, it is practically always sufficiently developed to take 
care of this or even somewhat larger amounts of starch 
without difficulty. This action of starch is, however, rather 
unreliable. Peptonization, or, as it should be called, pancreat- 
ization, of the food, if properly done, also usually prevents 
the formation of large curds. If not properly done, as was 
probably the case in this instance, it is ineffective. Boil- 
ing the food for five or ten minutes in a single boiler will 
also prevent the formation of large casein curds. 

The reddened tongue requires no treatment. Change of 
nipples and regulation of the diet will correct it. 

The bowels may be moved, if necessary, by enemata of 
suds or sweet oil, suppositories of soap, gluten or glycerin, or 
by milk of magnesia, in doses of from one-half to one tea- 
spoonful, once or twice daily. 



DISEASES OF GASTRO-ENTERIC TRACT. 1 71 

CASE 43. Ralph C, two years old, had always been well 
except for an occasional attack of acute indigestion. He 
had had nothing unusual for supper, but had eaten a good 
deal hurriedly and had been a good deal excited after supper. 
He began to vomit and to be feverish about midnight. 
The vomitus consisted first of his supper and then of water 
and mucus. He had apparently had no pain, and had been 
clear mentally. The bowels had not moved. He had no 
cough. He was seen at 5 a.m. 

Physical Examination. He was well developed and nour- 
ished, but a little pale. He vomited twice during the examina- 
tion. He was perfectly clear mentally. There was no motion 
of the alae nasi and the respiration was quiet. There was no 
rigidity of the neck. The pupils were equal and reacted to 
light. The tongue was moist, moderately coated and not 
reddened. The throat was normal. The heart and lungs 
were normal. The abdomen was a little sunken and lax. 
There was no tenderness, muscular spasm, tumor or dullness. 
The liver was just palpable, the spleen was not. The extremi- 
ties were normal. There was no spasm or paralysis. The 
knee-jerks were equal and normal; Kernig's sign and the neck 
sign were absent. There was no rash. The membranae 
tympanorum w^ere normal. The rectal temperature was 
103.5° F., the pulse 130, the respiration 30. 

Diagnosis. The sudden appearance of vomiting and fever 
is consistent at this age with the onset of almost any acute 
disease, and It Is often Impossible as early as this to make a 
positive diagnosis. Certain diseases are more probable, 
however, than others. These are. In the first place, acute 
indigestion, pneumonia, and scarlet fever; in the second 
place, tonsillitis, influenza, otitis media and meningitis, 
especially of the cerebrospinal form. 

The normal ear drums rule out otitis media; the absence 
of reddening of the throat and enlargement of the tonsils, 
tonsillitis. Meningitis, beginning with such acute symptoms 
as In this Instance, would almost certainly have shown by 
this time some signs of meningeal Irritation, none of which 
are present. The relatively slow rate of the respiration In 
comparison with the pulse practically rules out pneumonia. 



172 CASE HISTORIES IN PEDIATRICS. 

The absence of cough, of motion of the alae nasi and of 
physical signs in the lungs, together with the quiet respira- 
tion, are also against it, but not nearly as important as the 
relatively low rate of the respiration. The absence of inflam- 
mation of the throat and enlargement of the papillae of the 
tongue is against scarlet fever, but does not rule it out, as 
they might not have developed at this time. The rash would 
not, of course, have appeared thus early. Scarlet fever is, 
therefore, a possibiHty. Influenza is always a possibility 
with this history, as its manifestations are so manifold. 
The abdominal type is, however, much less common at this 
age than the respiratory type. The history of attacks of 
acute indigestion in the past, the hurried and hearty supper 
with the subsequent excitement, the absence of the signs 
characteristic of other diseases and the fact that acute in- 
digestion is very common while the other conditions to be 
considered are relatively rare, make the diagnosis of acute 
indigestion altogether the most probable. The final diag- 
nosis is, therefore. Acute Indigestion, with the bare pos- 
sibility that it may be scarlet fever or influenza. In this 
instance there is nothing to show what element or elements 
of the food caused the trouble. Therefore the Type of 
indigestion must be left Undetermined. Twenty-four, or at 
most forty-eight hours, wiU settle the diagnosis positively, 
either by the cessation of the symptoms or the development 
of something more definite. 

Prognosis. The prognosis as to life is, of course, absolutely 
good. The vomiting will probably cease during the day. 
He will, however, probably have more attacks unless his diet 
and routine are very carefully regulated. 

Treatment. The treatment should be on the basis of the 
diagnosis of acute indigestion. It will do no harm if the 
true diagnosis proves to be scarlet fever or influenza. The 
first thing to do is to cleanse the stomach. The quickest and 
most effective way to do this is to wash out the stomach. 
This is a very simple operation in a child of this age. A soft 
rubber catheter. No. 16 American, is used. It should be 
passed through the mouth and the stomach washed with 
plain water, or a weak solution of bicarbonate of soda, until 



DISEASES OF GASTRO-ENTERIC TRACT. 1 73 

the wash water returns clear. The stomach may also be 
cleansed, but less quickly and effectually, by giving copious 
drinks of water which will probably be immediately vomited. 
Food should be entirely withheld for from eight to twelve 
hours. Whey or broth, in one or two-ounce doses, every one 
or two hours, may then be given. A solution of bicarbonate 
of soda, one-half teaspoonful to a glass of water, given in 
teaspoonful doses every fifteen to thirty minutes, will prob- 
ably help to quiet the stomach. 

After the stomach has been cleansed and rested for an hour 
or two, a dessertspoonful of castor oil should be given. This 
may be vomited, but will probably be retained. If it is 
vomited, one-half teaspoonful doses of milk of magnesia, 
given at hour intervals, until three teaspoonfuls have been 
given, will probably be retained. 

Sponge baths of 95% alcohol and water, equal parts, at 
90° F,, will reduce the fever and make the child more com- 
fortable. 



a 

174 CASE HISTORIES IN PEDIATRICS. 

CASE 44. John F., the third child of healthy parents, 
was born at full term after a normal labor, was normal at 
birth and weighed eight pounds and twelve ounces. He was 
put at once on a weak modified milk, as there was no breast 
milk. The milk was gradually strengthened until, when he 
was three and one-half weeks old, he was taking a mixture 
containing about 5% of fat, 3.50% of sugar and 1% of pro- 
teids. He thrived on this until he was five weeks old, when 
his temperature suddenly rose to 103.8° F. and his abdomen 
became distended. He then had a large, watery, green, foul 
movement and the temperature dropped to 100.8° F. He 
was given a half a teaspoonful of castor oil and put on barley 
water containing 1.50% of starch. He had several small 
movements like the first from the castor oil. Twenty-four 
hours later, as he seemed much better, his mother put him 
back on the milk mixture. The temperature rose again in a 
few hours to 103.8° F., the abdomen became distended again 
and he became stupid and twitchy. He was seen in con- 
sultation that evening. 

Physical Examination. He was fairly developed and nour- 
ished and of fair color. The fontanelle was a little depressed. 
There was no rigidity of the neck. The pupils were equal and 
reacted to light. The mouth was dry; the tongue slightly 
coated. The heart and lungs were normal. The abdomen 
was much enlarged, tense and everywhere tympanitic. There 
was no localized muscular spasm. The liver and spleen were 
not palpable. The extremities were normal. There was 
considerable spasm of both arms and legs with a tendency to 
twitching; there was no paralysis; the knee-jerks were equal 
and lively; Kernig's sign was absent. There was no enlarge- 
ment of the peripheral lymph nodes. There was no evidence 
of inflammation about the navel. The rectal temperature 
was 103.5° F. 

Diagnosis. There can be no doubt, of course, that the 
location of the disturbance is in the intestine. The green, 
foul movements, the high temperature and the evidences of 
toxic absorption show that there is something more than a 
disturbance of the equilibrium of digestion, that fermentative 
processes are going on in the bowel and that the condition is 



DISEASES OF GASTRO-ENTERIC TRACT. 1 75 

bacterial in origin. The smaH number of movements and 
the absence of mucus and blood show that the intestinal wall 
is probably not involved. The diagnosis is, therefore, Acute 
Indigestion with Fermentation. 

The stupor, the spasm of the extremities and the tendency 
to twitching would be considered by many to be evidences of 
a complicating meningitis. Meningitis is, however, a very 
unusual compHcation of the acute diarrheal diseases of in- 
fancy, while symptoms of meningeal irritation are not at all 
uncommon. Meningitis is, therefore, extremely improbable 
in this instance. The depression of the fontanelle alone is, 
moreover, almost sufficient to rule it out. The nervous symp- 
toms are to be regarded, therefore, merely as evidences of 
toxic absorption, or possibly as effects of the high temperature. 

It is possible that the excessive amount of fat in the food 
may have predisposed the baby to this attack by disturbing 
the equilibrium of the digestion. 

Prognosis. The condition is a grave one because of the 
age of the patient, the distention of the abdomen, the high 
temperature and the presence of nervous symptoms. The 
facts that the temperature dropped and the general condition 
improved rapidly after he was cleaned out and the milk 
stopped make it probable that a repetition of the treatment 
will have the same result. Put in figures, the chances are 
probably about three to one in favor of recovery. 

Treatment. The first thing to do is to empty the bowels. 
Castor oil is the safest and most effectual drug for this pur- 
pose. As the object of the oil is to clean out the bowels, the 
dose must be large enough to do it. Two teaspoonfuls is none 
too large, even for a baby of five weeks. In the meantime the 
colon should be irrigated in order to relieve the distention and 
empty the lower bowel. It will probably not be necessary 
to repeat it unless the distention recurs, because the chief 
seat of the trouble is in the small, not in the large, intestine. 

All food must be stopped. Babies bear the withdrawal of 
food without much difficulty, but cannot get on without 
water. They must be given as much water in the twenty- 
four hours as they normally get in their food. This baby 
needs at least twenty ounces of water in the twenty-four 



176 CASE HISTORIES IN PEDIATRICS. 

hours. If he will not take it from the bottle, spoon or dropper, 
it must be given with a stomach tube. In urgent cases it 
may be given by the bowel by the drop method, or subcu- 
taneously in the form of physiological salt solution. It will 
probably not be necessary to have recourse to these measures 
in this instance. The water not only prevents the loss of 
fluid from the tissues, thus keeping up the equilibrium of 
the circulation, but favors the elimination of toxic substances 
through the kidneys. 

The duration of the period of starvation depends on the 
temperature, the character of the movements and the general 
condition of the patient. It is impossible to state in advance 
how long this period will be in any individual case. In all 
probability, not more than twenty-four or forty-eight hours 
in this instance. 

It is wiser, on general principles, to begin feeding with some 
other food than milk. This is usually some form of starch 
or sugar. This baby is only five weeks old and ought not to 
have its power of digesting starch pushed too hard. A 0.75% 
solution of starch in the form of barley water, with 7% of 
milk sugar, will be suitable to begin with. 

When it is time to begin milk the best milk is human milk. 
Nothing else compares with it in these conditions. Next to 
it is modified cow's milk. In general, it is wiser to begin with 
some combination very low in fat. The substitution of whey 
for some of the feedings of barley water and sugar will be a 
good way to begin in this instance. The addition of a small 
amount of skimmed milk to the barley water and sugar mix- 
ture is another way. Another is a whey mixture low in fat 
and relatively high in proteids, such as fat 1%, sugar 6%, 
whey proteids 0.75%, casein 0.25%, without lime water. 

There are no drugs which can have any effect on the local 
condition. No stimulants are needed at present. The castor 
oil and irrrigation will, in all probability, relieve the disten- 
tion. The temperature is not high enough or the nervous 
manifestations marked enough to require special treatment. 
The emptying of the bowels and the water diet will diminish 
the toxemia, and the temperature and nervous symptoms, 
which are caused by it, will then gradually disappear. 



DISEASES OF GASTRO-ENTERIC TRACT. 1 77 

CASE 45. Gertrude Y,, three years old, had always been 
very well and strong. There had been no known indiscre- 
tion in diet. She began to be sick during the night of No- 
vember 19, and the next morning began to have many loose, 
green movements, not accompanied by much pain. When 
seen by her physician that evening her temperature was 
103.8^ F., and she was delirious. He gave her calomel and 
various intestinal antiseptics and limited her food to toast 
water, soft toast, and a little malted milk. The diarrhea 
continued, while tenesmus developed on the twenty-first and 
blood appeared in the stools on the twenty-second. The 
stools then began to diminish in number and to contain less 
blood, while the temperature gradually fell, reaching normal 
in the morning of November 25. She was then given al- 
bumin water in place of the carbohydrate diet which she 
had been taking. Her temperature immediately rose again, 
the diarrhea and tenesmus increased and there was much 
more blood in the stools. She was seen in consultation in 
the afternoon of November 26. 

Physical Examination. She had evidently lost consider- 
able weight and was pale. She was perfectly clear mentally. 
Her tongue was considerably coated, but not very dry. 
The heart and lungs were normal. The abdomen was 
sunken, but otherwise normal. The liver and spleen were 
not palpable. The extremities were normal. There was no 
spasm or paralysis. The peripheral lymph nodes were not 
palpable. Her rectal temperature was 102° F. 

The stools were small, loose, greenish-brown in color, and 
contained much mucus and a little blood. 

Diagnosis. The numerous small movements of mucus 
and blood associated with pain are so characteristic of in- 
fectious diarrhea that no differential diagnosis from the other 
forms of diarrhea is necessary. The only other possibility, 
intussusception, can be ruled out on the slow onset, the ab- 
sence of vomiting and the negative examination of the ab- 
domen. The improvement in the sym.ptoms when she was 
taking carbohydrates and their recurrence when they were 
stopped and she was given proteid shows that the infection 
is caused by some organism which produces toxic substances 



178 CASE HISTORIES IN PEDIATRICS. 

from proteids, while it does not from carbohydrates. In 
the vast majority of instances this organism is some form of 
the dysentery bacillus, although others, such as the colon 
bacillus and streptococci, may act in the same way. It is 
safe to assume, therefore, that the dysentery bacillus is the 
infecting organism in this instance. Fortunately it makes 
no difference in the treatment which of these organisms it is. 
The diagnosis is, therefore, Infectious Diarrhea Caused 
BY the Dysentery Bacillus. 

Prognosis. Infectious diarrhea of this type is always a 
serious disease. The patient is not out of danger until he 
is well. It is impossible to say what course it may take in 
this instance. The fact that she did so well when on a car- 
bohydrate diet makes it probable, however, that she will 
again do well when she is put back on it. The chances seem 
to be about four out of five in favor of recovery. 

Treatment. The treatment consists chiefly in giving her a 
diet from which the dysentery bacilli cannot form toxic 
products and which will tend to restore the normal intestinal 
flora. Such a diet must be made up of carbohydrates. She 
should be given a 7% solution of milk sugar freely. The 
sugar may be dissolved in one of the cereal waters, if desired. 
Milk sugar is the best of the sugars in this condition, be- 
cause it is more slowly broken down and absorbed than the 
other sugars and is the sugar best fitted to reestablish and 
maintain the normal intestinal flora. She may also be given 
cereals, bread, toast and cracker, if desired. In a few days, 
if she is doing well, skimmed milk may be added cautiously 
in order to supply some of her proteid needs. Care must 
be taken, however, that there is for some time a considerable 
excess of carbohydrates. 

Irrigation of the bowels once or twice in the twenty-four 
hours with physiological salt solution, or a 1% solution of 
boracic acid, is indicated to cleanse the colon. It has no 
direct healing action. The irrigation should be given with a 
soft rubber catheter. No. 25 French, passed as high as possible 
into the bowel, with the patient lying on the back with the 
hips elevated. The fluid is then allowed to run in from a bag 
hung not more than two feet above the level of the patient. 



DISEASES OF GASTRO-ENTERIC TRACT. 1 79 

It should be allowed to run in until the abdomen is slightly 
distended, then allowed to run out, and so on, until the wash 
water returns clean. The object of the irrigation is to cleanse 
the colon. Enough liquid should be used to do this, no matter 
whether it is much or little. Irrigation should never be done 
more than twice in the twenty-four hours. If it depresses or 
disturbs the patient much, it should be omitted, as under 
these conditions it does more harm than good. 

Bismuth, salol and other preparations of like nature have, 
in the author's opinion, little or no effect on infectious 
diarrhea. It disturbs the patient to take them and interferes 
with the administration of food and water. It will be wiser, 
therefore, not to give them in this instance. Paregoric and 
other preparations of opium are, on general principles, contra- 
indicated in all forms of diarrhea, because their action is to 
diminish the number of movements by depressing peristalsis 
and not by relieving the cause of the increased peristalsis. 
The increased peristalsis is nature's effort to get rid of the 
poisonous intestinal contents. Nature's effort should, there- 
fore, not be interfered with. In infectious diarrhea of the 
dysenteric type, however, when there is a very large number 
of small movements accompanied by pain and tenesmus 
which prevent the patient from getting proper rest, it is 
allowable to give opium in some form to diminish the excessive 
peristalsis and to quiet the patient. There is no danger, if 
proper care is used, of doing harm by retaining the intestinal 
contents too long. Paregoric, in doses of ten or fifteen drops, 
may be given in this instance, therefore, if necessary. 



l8o CASE HISTORIES IN PEDIATRICS. 

CASE 46. Bradford J., eleven months old, was the sixth 
child of healthy parents. He was born at full term, after 
a normal labor, and weighed eight pounds. He was nursed 
for only three weeks and then was put on a mixture of whole 
milk and water with MeUin's Food. He did well on this 
food and when taken sick, three weeks before, weighed 
twenty-two pounds. 

He was taken rather suddenly sick with fever and diar- 
rhea. The stools from the first contained mucus and blood, 
and, after a few days, pus. The fever, which was never 
very high, lasted about ten days, but he continued to have 
from seven to ten stools daily, which contained mucus, blood 
and pus. He had not vomited. He lost about two pounds 
in weight during the first ten days, but had not lost any since. 
He was cleaned out with castor oil in the beginning and given 
nothing but barley water for two days. He was then given 
a mixture of whole milk, barley water and milk sugar and 
finally, as he did not improve, a mixture of barley water, 
whey and milk sugar. He took greedily whatever was of- 
fered to him. He was seen in consultation after he had been 
sick for three weeks. 

Physical Examination. He was a large well developed 
baby, but somewhat flabby and pale. The anterior fon- 
tanelle was closed and he had six teeth. His tongue was 
moist and slightly coated. The heart and lungs were normal. 
The level of the abdomen was that of the thorax. Nothing 
abnormal was detected in it. The lower border of the liver 
was palpable 2 cm. below the costal border in the nipple 
line. The spleen was not palpable. The extremities were 
normal. There was no spasm or paralysis and the periph- 
eral lymph nodes were not palpable. 

The stools were small, green, a little frothy, and contained 
mucus, pus and blood. 

Diagnosis, The numerous small movements, containing 
mucus, pus and blood, are so characteristic of infectious 
diarrhea that no differential diagnosis from the other forms 
of diarrhea is necessary. The absence of fever and the good 
general condition show that the infection is a mild one. 
The persistence of the symptoms on a diet almost entirely 



DISEASES OF GASTRO-ENTERIC TRACT. l8l 

composed of carbohydrates is strong evidence that neither 
the dysentery bacillus nor other organisms which have 
similar biological characteristics is the infecting agent. 
There is, however, another class of organisms which may 
cause the same symptoms and which thrives on carbohydrates. 
These organisms are those of the gas bacillus group. They 
are probably the infecting organisms in this instance. It 
will be wise, however, to plant a portion of a stool on a sterile 
sugar solution in a fermentation tube and incubate it over 
night in order to determine whether gas is formed or not. 
This was done and a considerable amount of gas was formed 
in the tube, thus verifying the diagnosis of Infectious Diar- 
rhea Caused by the Gas Bacillus. 

Prognosis. Infectious diarrhea is always a serious dis- 
ease. The patient is not out of danger until he is well. 
In this instance the baby has withstood the infection so well 
and is in such good condition in spite of an unsuitable diet 
that rapid recovery may be expected when his diet is changed. 

Treatment. The treatment consists chiefly in giving him 
a diet on which the gas bacillus cannot thrive, that is, one 
high in proteids and low in carbohydrates. Clinical ex- 
perience shows that it should also be low in fat. Lactic acid 
forming organisms are antagonistic to the growth of the gas 
bacillus. Buttermilk, which is a food high in proteids and 
low in fat and carbohydrates, also contains lactic acid form- 
ing organisms. It is, therefore, the food indicated in this 
instance. It will be well to give it at first diluted with 
water. Five ounces of buttermilk and three ounces of water 
may be given every three hours. It should not, of course, 
be pasteurized or boiled, as these procedures would destroy 
the lactic acid bacteria. 

Bismuth, salol and other preparations of like nature have, 
in the author^s opinion, little or no effect on infectious diar- 
rhea. It disturbs the patient to take them and interferes 
with the administration of food. It will be wiser, there- 
fore, not to give them in this instance. Irrigation of the 
bowels seems hardly necessary for this baby and there are 
no indications for the use of opium. (See Case 45.) 



1 82 CASE HISTORIES IN PEDIATRICS. 

CASE 47. Pearl P., one year old, had always been well. 
She was fed on raw, unmodified cow's milk. She had had some 
slight disturbance of the bowels about the middle of July, 
but had almost entirely recovered. She suddenly began to 
vomit about noon, July 28. The vomitus consisted at first 
of milk, but soon became watery; it did not contain bile. 
Diarrhea came on in a few hours. The movements were at 
first fecal in character, but soon became watery and colorless. 
She vomited and had a movement every few minutes. Thirst 
became marked, but everything taken was vomited. Castor 
oil and calomel were also vomited. Her temperature that 
night was 104° F. The next morning she was much collapsed. 
She was seen in consultation at 9 a.m., twenty-one hours after 
the onset. 

Physical Examination. She had evidently lost much weight. 
Her skin was dry and her extremities cold and blue. The 
fontanelle was much depressed. Her eyes were wide open and 
staring, but she took very little notice. The pupils were 
equal and reacted to light. Her tongue was dry. She held 
her head rigidly backward. The heart and lungs were normal. 
The abdomen was much sunken but not rigid. Neither liver 
nor spleen were palpable. She tossed her arms about con- 
stantly. Her legs were somewhat rigid; the knee-jerks were 
equal and exaggerated ; Kernig's sign could not be determined 
because of the rigidity. The rectal temperature was 104° F., 
the pulse 160, and the respiration 60. The vomitus and move- 
ments looked like turbid water. 

Diagnosis. The history and physical examination are so 
typical of Cholera Infantum that there is no need of con- 
sidering any other disease. The nervous symptoms are due 
to a combination of toxemia and loss of fluid. 

Prognosis. The prognosis is very grave. There is probably 
not more than one chance in twenty of recovery. The 
disease is, however, to a certain extent, self-limited. If she 
lives through the next thirty-six hours the chances of recovery 
will be very much better. 

Treatment. The main indications for treatment in this 
condition are (i) to empty the stomach and bowels of their 
toxic contents; (2) to supply fluid to the tissues which are 



DISEASES OF GASTRO-ENTERIC TRACT. I83 

being so seriously drained ; (3) to restore the surface circula- 
tion; (4) to reduce the temperature; (5) to keep the patient 
alive until the disease has run its course. 

Nature is already doing her best to empty the stomach and 
bowels. Nothing can be done to help her. Cathartics will be 
vomited and stomach washing and irrigation of the bowels 
will only increase the collapse. There is no objection, how- 
ever, to giving the baby cool water to drink, even if it is 
vomited, as it will make her more comfortable and help to 
wash out the stomach. 

The only way in which fluid can be supplied to the tissues 
is by the administration of physiological salt solution subcu- 
taneously. She should be given from four to eight ounces at 
a time, repeated every three or four hours if absorbed. 

The surface circulation is best restored by the application 
of heat externally in the form of heaters or hot packs. She 
should be at once surrounded with heaters and, if this is not 
successful, be put in a pack at 100° F., or a little higher. 
Restoration of the surface circulation will usually reduce the 
internal temperature. If it does not, irrigation of the colon 
with water at 90° F. will usually do so. Her temperature is 
hardly high enough to require this at present. 

It is useless to give stimulants or other drugs by the mouth, 
as they will not be retained. All drugs must, therefore, be 
given subcutaneously. The best stimulant is caffein. This 
may be given subcutaneously in the form of caffeine-sodium 
benzoate. The dose for this baby is one quarter of a grain 
every three or four hours. Strychnia, in doses of 1-500 of a 
grain, may also be given subcutaneously, if necessary. Alcohol 
is contra-indicated. Adrenalin is indicated if the cardiac 
failure increases. Unfortunately it has very little action when 
given subcutaneously, and intravenous injection is very 
difficult in a baby of this age. If the restlessness increases, 
morphia, in doses of i-ioo of a grain, given subcutaneously, 
will aid by quieting her and saving her strength. 

Food of any description is contra-indicated until the vomit- 
ing and diarrhea have stopped. The first food given should 
be a 1% solution of starch in the form of barley water, with 
5% of milk sugar added. 



lS4 CASE HISTORIES IN PEDIATRICS. 

CASE 48. Catherine L., six and one-half years old, was 
the first child of healthy parents. She was born about a 
month premature and for the first year had a feeble digestion 
and was very difficult to feed. During the first two years of 
her life she had repeated attacks of vomiting, some of which 
resembled the recurrent vomiting seen in older children. 
After this, however, these attacks ceased, although her diet 
always had to be very carefully regulated. There was always 
a tendency to constipation and attacks of indigestion. She 
had never had any very severe attacks of indigestion, how- 
ever, as they could always be aborted by care in the diet 
and early treatment. During the last year her digestion had 
been much stronger than ever before. Early in June she had 
an attack of what was supposed to be ordinary indigestion. 
Recovery from this was rapid, however, and she had been 
perfectly well until August 2 1 . That afternoon she went to a 
children's party and was a good deal excited. The food at the 
party was very simple and she did not over-eat. She began to 
vomit during the night. The vomitus contained a great deal 
of bile. The morning of the 226. her temperature was about 
100° F. She continued to vomit bile during the day and 
night of the 22d, and also a little in the morning of the 23d. 
The vomitus continued to contain much bile. The tempera- 
ture during the 22d and the morning of the 23d ranged 
between 100° F. and 101° F. Examination of the abdomen 
during the 22d showed nothing whatever abnormal. In the 
early morning of the 23d there was a little tenderness in the 
right iliac fossa, with a suggestion of spasm. There was and 
had been no pain in the abdomen. The bowels had been 
moved freely by enemata during the 22d. About noon of 
the 23d she had a chill and the temperature rose to 104° F., 
but soon began to drop again. At that time there was no 
pain in the abdomen, but muscular spasm and tenderness in 
the right iliac fossa were rather more marked. The blood 
count at that time showed 26,200 leucocytes. 

She was then given a dose of castor oil, which during the 
afternoon produced a movement containing more or less 
mucus. She was seen in consultation at 5 p.m. on the 23d. 

Physical Examination. Her face looked a little pinched, 



DISEASES OF GASTRO-ENTERIC TRACT. 185 

but she was bright and happy. She was not vomiting and 
had no pain whatever. The pupils were equal and reacted to 
light and accommodation. There was no rigidity of the neck. 
The ears were normal. The heart and lungs showed nothing 
abnormal. The level of the abdomen was considerably below 
that of the thorax. When very deep pressure was made in 
the right iliac fossa she said that it hurt her a little, but gave 
no evidence of pain unless questioned. In fact, she smiled 
and talked while the abdomen was being examined. There 
was also very slight muscular spasm in the right iliac fossa. 
No tumor could be felt and there was no dullness. The ab- 
domen was otherwise negative. The liver and spleen were 
not palpable or enlarged to percussion. The extremities 
showed nothing abnormal. There was no Kernig's sign. 
The knee-jerks were equal and lively. The temperature in 
the mouth was ioi° F., and the pulse 120. 

Diagnosis. The diagnosis in this case lies between tubercu- 
lar meningitis, acute indigestion and appendicitis. 

Tubercular meningitis should be thought of in this instance 
as in every illness in a child beginning with vomiting. It can 
be ruled out at once, however, on the absence of all signs of 
meningeal irritation and the presence of signs of trouble in 
the abdomen. The white count is also against tubercular 
meningitis, but does not rule it out, as there may be a leuco- 
cytosis in tubercular meningitis. 

The points in favor of acute indigestion are the previous 
history of attacks of indigestion and of feeble digestion in 
the past, the typical onset of the attack with vomiting of 
bile, the low temperature and the slightness of the physical 
signs of appendicitis. The points in favor of appendicitis 
are the persistence of the sym^ptoms after proper treatment 
for indigestion, the pinched face, the chill, the leuco- 
cytosis and the physical signs, namely, localized muscular 
spasm in the right lower abdomen and the slight tender- 
ness in this region on deep pressure. The persistence of the 
symptoms in spite of treatment is merely suggestive of ap- 
pendicitis and not inconsistent with acute indigestion. The 
chill is very suggestive of appendicitis, but chills do some- 
times occur in indigestion. A leucocytosis as high as 26,200 



1 86 CASE HISTORIES IN PEDIATRICS. 

practically never occurs in indigestion at this age, and in 
connection with the chill and the physical signs is extremely 
important in the diagnosis. The localized muscular spasm 
is almost pathognomonic of appendicitis when taken in con- 
nection with the other symptoms and signs. The deep 
tenderness is corroborative evidence of that furnished by the 
muscular spasm. It might be thought that the physical 
signs were too indefinite to be of much importance. This 
is not so, however, as indefiniteness of the physical signs is 
characteristic of appendicitis in childhood. Finally, the pre- 
vious attacks which were called indigestion may equally well 
have been recurrent attacks of appendicitis. The diagnosis 
of Appendicitis, therefore, seems positive. 

The condition of the appendix is always problematical. 
In this instance it is justifiable to conclude from the good 
general condition, the high white count and the mildness of 
the physical signs that perforation has certainly not occurred 
and that in all probability there is but little extension of the 
inflammation outside of the appendix. The appendix, how- 
ever, may very possibly be ulcerated and ready to perforate. 

Prognosis and Treatment. The prognosis is always more 
uncertain in childhood than in later life because of the 
greater difficulty in determining the exact condition of the 
appendix before operation. There is no question but that an 
immediate operation should be done in this instance. She 
is in good condition to bear an operation and, since it is im- 
possible to find out the exact condition of the appendix, it 
is far wiser to operate at once than to run the risk of extension 
of the inflammation or perforation. The prognosis with 
immediate operation is very good because the appendix has 
almost certainly not perforated and there is probably but 
little inflammation about it. 



DISEASES OF GASTRO-ENTERIC TRACT. 1 87 

CASE 49. Ethel H., four years old, was the extremely 
nervous child of nervous parents. She had always been well 
except for measles and chicken-pox. She vomited a little the 
morning of August 6, but seemed well in every way the next 
day. The following day, which was extremely hot, she went 
to Revere Beach and ate a considerable amount of ice cream. 
She slept fairly well that night, but on the morning of the 
9th vomited once and began to complain of pain about the 
navel. A physician, who was called, found the temperature 
102° F. The respiration was rapid, but the lungs were normal. 
He gave two teaspoonfuls of castor oil and stopped all food. 
She had three or four loose, foul movements, which contained 
a little mucus, but no blood, as the result of the castor oil. The 
abdominal pain continued and was very severe. The tempera- 
ture the morning of the loth was 103.5° F. The bowels 
moved three times during that day, the movements being of 
the same character. The abdominal pain continued. The 
evening temperature was 101° F. The pulse ranged between 
145 and 160, and the respiration between 40 and 80. There 
was no cough and the lungs remained normal. She vomited 
several times that night and, on account of the severe pain 
in the abdomen, slept but little. The temperature by rectum 
the morning of the nth was 99.6° F., the pulse 140. She 
took no food, but drank considerable water. She vomited 
several times that morning. She had had a little brandy, 
some bismuth and chalk mixture and two doses of Castoria. 
She was very restless and complained constantly of pain in 
the abdomen. The abdomen was distended and tender from 
the first, the physician thought less so that morning. The 
physician had felt that the pain was exaggerated because 
of the nervous temperament of the child. She was seen in 
consultation at noon, August 11. 

Physical Examination. She was well-developed and fairly 
nourished. There was moderate pallor. She was very rest- 
less, tossing from side to side and constantly crying out from 
pain in the abdomen. She lay on her back with the legs 
flexed on the abdomen; extending them caused pain. Her 
face looked pinched. The tongue was dry, but not coated. 
The heart and lungs were normal. The abdomen was only 



1 88 CASE HISTORIES IN PEDIATRICS. 

moderately enlarged, but very tense. No localized spasm 
could be made out. She complained whenever the abdomen 
was touched, but no more so on deep than on light pressure 
There was no localized tenderness. There were no signs of 
fluid in the abdomen. The liver and spleen were not palpable. 
Rectal examination showed nothing abnormal, but caused 
much pain. The extremities were normal. There was no 
spasm or paralysis. The knee-jerks and Kemig's sign could 
not be obtained because of the child's resistance. The rectal 
temperature was ioi°F.; the pulse, 156. A movement, 
passed during the examination, consisted of a few small 
masses of brownish mucus. 

Diagnosis. Pneumonia is suggested by the sudden onset 
and the comparatively greater rise in the rate of the respira- 
tion over that of the pulse. The location of the pain in the 
abdomen is not against pneumonia, because the pain in 
pneumonia in childhood is often localized in the abdomen. 
The abdomen is also often tense in the early stages of pneu- 
monia in childhood. The drop in the temperature without a 
corresponding diminution in the rate of the respiration, the 
absence of cough, grunting respiration and movement of the 
alse nasi, the absence of physical signs in the lungs and 
the pinched face are together sufficient to exclude pneumonia. 

The free movements of the bowels are sufficient to rule out 
intestinal obstruction. 

The diagnosis lies, therefore, between intestinal toxemia 
and appendicitis. The history of eating ice cream on a hot 
day is suggestive of intestinal toxemia, but is not inconsistent 
with appendicitis. The continuance of the symptoms in 
spite of catharsis and starvation is against toxemia, but does 
not exclude it. The character of the stools is much against 
toxemia. The vomiting is consistent with either condition 
and hence is of no importance in the differential diagnosis. 
Distention of the abdomen is, however, unusual in toxemia, 
and tenderness and pain extremely rare. These two points 
are sufficient in themselves to turn the scale in favor of 
appendicitis. 

The general abdominal distention accounts for the lack of 
localized spasm and tenderness and suggests a beginning or 



DISEASES OF GASTRO-ENTERIC TRACT. 1 89 

developing general peritonitis. The drop in the temperature 
with no improvement in the other symptoms is strong evi- 
dence that perforation has occurred and peritonitis begun. 
The diagnosis is, therefore, Appendicitis with probable 
perforation and beginning peritonitis. 

An examination of the blood was not made in this instance 
and would not have helped, because a high white count is 
consistent with either condition. Moreover, a low white 
count is consistent with either depression after perforation 
or intense toxemia. 

Prognosis and Treatment. The prognosis in this instance 
is practically hopeless. The only chance lies in immediate 
operation. 



IQO CASE HISTORIES IN PEDIATRICS. 

CASE 50. Rosamond B. was seven and a half years old. 
Her mother had valvular heart disease and was markedly 
neurotic. Her mother's family was extremely neurotic and 
several members had been insane. Her father's family was 
rheumatic. 

She was a decidedly neurotic child and was very fussy 
about her diet, and had also been fed very carefully because of 
the rheumatic family history. Her appetite was very good. 
She had had no symptoms of indigestion except that her 
bowels were always constipated. She had been taking cascara 
regularly for more than a year. 

She had had no unusual excitement, had not exerted her- 
self unduly, and had done nothing unusual during November 
28, She began to vomit at 5 a.m., November 29. She vomited 
every few minutes during that day and night and about 
every two hours during the 30th up to 9 p.m., when she was 
seen in consultation. In all, she vomited fifty- two times 
during this period. The vomiting was not explosive. The 
vomitus at first contained a little of the food taken at supper, 
but after this consisted of water mixed with a little mucus. 
It did not contain bile. She had taken nothing by mouth 
except water in small quantities and cracked ice, which had 
been given because of the extreme thirst. Both had been 
vomited immediately. The bowels had been moved freely 
by enemata. The stools were normal in character. Her 
temperature, taken in the axilla, had ranged between 99° F. 
and 100° F. She had been rather restless and had slept 
but little. Bromide, given by enema, had quieted her 
considerably. She had had no pain. 

Physical Examination. She was tall and sHght. Her color 
was good. The pupils were equal and reacted to both light 
and accommodation. There was no rigidity of the neck. 
She was perfectly clear mentally. Her tongue was moist 
and but slightly coated. Her breath had a slightly sweetish 
odor. The heart, lungs and liver were normal. The level of 
the abdomen was that of the thorax. There was no muscular 
spasm and no tenderness. Palpation was easy and disclosed 
nothing abnormal. The spleen was not palpable; the area 
of dullness was normal. The extremities showed nothing 



DISEASES OF GASTRO-ENTERIC TRACT. I9I 

abnormal. There was no spasm or paralysis. The knee- 
jerks were equal and lively. Kernig's and Babinski's signs 
were both absent. The cervical and axillary lymph nodes 
were somewhat enlarged; the inguinal were not. The 
rectal temperature was 99° F., the pulse 96, the respiration 
20. She did not object to the examination, but gave the 
impression that she was decidedly neurotic. 

The urine contained neither albumin nor sugar, but gave 
the tests for both acetone and diacetic acid. 

Diagnosis. The conditions which may be reasonably 
considered in this instance are meningitis, more likely tuber- 
cular than cerebrospinal, intestinal obstruction, nervous 
vomiting and recurrent vomiting. 

Meningitis can be at once excluded on the combination of 
the absence of all signs of meningeal irritation, the low tem- 
perature and the excessive amount of the vomiting compared 
with the other symptoms. It can be so positively excluded 
that lumbar puncture is not justified as a method of diagnosis, 
although this ought to be done in every case in which there is 
a reasonable chance of meningitis because of the good which 
can be accomplished by the serum treatment in cerebrospinal 
meningitis, especially when the diagnosis is made early. 

Intestinal obstruction can also be excluded on the char- 
acter of the vomitus, the absence of physical signs in the 
abdomen, the clean tongue, the free movements from the 
bowels, the low temperature and the good general condition. 

The neurotic family history and the neurotic disposition 
of the patient are consistent with either nervous or recurrent 
vomiting. So are the character of the vomitus, the absence 
of physical signs, theiclean tongue, the low temperature and 
the good general condition. The excessive amount of the 
vomiting and the absence of any cause for nervous vomiting 
make this diagnosis very improbable. In fact, the whole 
picture is characteristic of what is known as Recurrent 
Vomiting. It may be said that it is incorrect to call the 
condition *' recurrent vomiting '* when the child has never 
had anything like it before. It must be remembered in this 
connection, however, that there is always a first time for 
everything. Since acid intoxication is probably one of the 



192 CASE HISTORIES IN PEDIATRICS. 

causes of recurrent vomiting, the sweet odor of the breath and 
the presence of acetone and diacetic acid in the urine might 
be thought indicative of this condition as against nervous 
vomiting. This is not so, however, as the abstinence from 
food for thirty-six hours will account for them equally well. 

Prognosis. There is no danger as to life. The vomiting 
will probably not persist more than forty-eight hours longer, 
more likely a shorter than a longer time. The duration will 
depend somewhat on whether the treatment is rational or 
not. 

Treatment. Before taking up the treatment it must be 
remembered that recurrent vomiting is probably merely a 
symptom-complex of manifold etiology. In most instances it 
is a manifestation of some disturbance of metabolism. This 
disturbance is sometimes an intoxication from the acetone 
bodies (the so-called acid intoxication) and sometimes an 
intoxication from uric acid. IN^ost often the nature of the 
disturbance is unknown. In so: le instances it is a manifesta- 
tion of inflammation of the appendix. In this instance ap- 
pendicitis can be immediately ruled out on the absence of all 
signs of inflammation in this region. It is impossible to state, 
however, what the nature of the disturbance of metabolism 
is. The sweet breath and the presence of acetone bodies in 
the urine suggest acid intoxication. They do not prove it, 
however, because starvation will also account for them. It 
is reasonable, however, to treat the condition on this basis. 
Such treatment can do no harm if it does no good. 

This treatment consists in the administration of bicarbon- 
ate of soda. From one-half ounce to an ounce should be given 
in twenty-four hours. The attempt should be made to give 
it by mouth in teaspoonful or tablespoonful doses of a solu- 
tion of bicarbonate of soda, one teaspoonful to a glass of water, 
every fifteen to thirty minutes. It is well to persist, even if 
the soda is vomited. High enemata of a solution of bicarbon- 
ate of soda, two drams to six ounces of water, should be 
given every four hours. The child should be kept perfectly 
quiet, in a cool, dark room. No food should be given by 
mouth. It will probably be necessary on account of the 
excessive thirst to give small amounts of liquid, even if vom- 



DISEASES OF GASTRO-ENTERIC TRACT. I93 

ited. Water or carbonated water, in doses of from one tea- 
spoonful to one tablespoonful, or cracked ice, may be given. 
If she is restless or sleepless from vomiting, ten or fifteen 
grains of bromide of soda may be given in the enemata of 
bicarbonate of soda. If this is not effective, morphia, gr. yg, 
may be given subcutaneously. Food should not be given 
until t^velve hours after the vomiting has stopped. Whey, 
cereal waters, or cereal waters with sugar, should then be 
given, beginning with an ounce every hour and increasing 
the amount if they are retained. These foods are given in- 
stead of broths or albumin water because the carbohydrates 
antagonize the acid intoxication and have more food 
value. 



194 CASE HISTORIES IN PEDIATRICS. 

CASE 51. Malcolm B., the third child of healthy parents, 
was born at full term after a normal labor. He was normal at 
birth and weighed eight pounds. He was nursed for nine 
months, but during the last two months had had one or two 
feedings of modified milk daily in addition. He was then 
weaned and given an unmodified top milk, which contained 
about 7.50% of fat, 4.50% of sugar and 3.50% of proteids. 
The bowels, which had previously moved regularly, immedi- 
ately became constipated, enemata, suppositories or some 
drug being always required to get a movement. The move- 
ments were white, dry and crumbling and had a disagreeable 
acid odor. There was no vomiting. He took nothing but 
this top milk, except occasionally a little broth with rice, 
until he was fourteen months old. He was then changed to 
five feedings of seven ounces of a top milk and Mellin's Food 
mixture, which contained about 5.70% of fat, 6% of sugar 
and 3% of proteids, and after about three weeks was given a 
little beef juice in addition. The constipation was rather less 
marked on this diet but still very troublesome. He was seen 
when fifteen months old. 

Physical Examination. He was well developed and nour- 
ished, but flabby and a little pale. The fontanelle was 2 cm. 
in diameter. He had seven teeth. His tongue was clean. 
There was no rosary. The heart and lungs were normal. 
The abdomen was negative, its level a little below that of the 
thorax. The liver was just palpable. The spleen was not 
palpable. The extremities were normal. There was no spasm 
or paralysis; the knee-jerks were equal and normal; Kernig's 
sign was absent. There was a slight general enlargement of 
the peripheral lymph nodes. The weight was twenty-two 
pounds and eight ounces. 

Diagnosis. The chief trouble is, of course, Constipation. 
Constipation is, however, really a symptom and not a disease. 
It is not a satisfactory diagnosis unless modified by some 
term denoting the cause of the constipation. In this instance 
the cause of the constipation is very evident, namely, the 
excessive amount of fat in the food. No more than four 
per cent of fat should ever be given ; he was getting nearly 
twice that. The white, dry and crumbling stools are most 



DISEASES OF GASTRO-ENTERIC TRACT. 195 

characteristic, being composed of unutilized fat in the form 
of soaps. The improvement after the change of food, one 
result of the change being a reduction in the amount of fat, is 
further evidence that an excess of fat was the cause of the 
constipation. A part of the improvement may possibly, 
however, be attributed to the malt sugar in the Mellin's Food 
and the beef juice, both of which usually have a laxative 
action. The flabbiness of the skeletal muscles indicates an 
additional atonic element in the etiology, because, when the 
skeletal muscles are feeble, the intestinal muscles are usually 
in the same condition. 

Prognosis. The prognosis is good for rapid recovery, 
because the chief cause of the trouble, the excess of fat in the 
food, can be removed at once. 

Treatment. The treatment is, of course, primarily by 
regulation of the diet to remove the cause of the trouble. 
Whole milk, or whole milk with an ounce of oat water to 
each feeding, will probably give a sufficiently low fat. He is 
old enough to have something beside milk; in fact, babies of 
his age are almost certain to do badly in some way if they do 
not have something to eat beside milk. A reasonable diet to 
start him on is as follows: 

Whole milk or whole milk with oat water. 

Beef juice, one or two tablespoonfuls ; or 

Mutton or chicken broth, two to four ounces, once daily. 

Bread or zwiebach in broth or beef juice. 

Barley jelly, oat jelly, farina or rice, one to three table- 
spoonfuls twice daily. 

Orange juice, one to three tablespoonfuls, once daily. 

While regulation of the diet is removing the cause of the 
trouble, it may be necessary to relieve the symptom, constipa- 
tion, for a time by the use of enema ta of suds or sweet oil, 
suppositories of soap, glycerin or gluten, or milk of magnesia, 
in doses of from one-half to one teaspoonful once or twice 
daily. 

It goes without saying that fresh air, a good routine and 
everything which tends to improve the general condition will 
aid in the relief of the constipation by improving the muscular 
tone and removing the atonic element. 



196 CASE HISTORIES IN PEDIATRICS 

Massage of the abdomen for five or ten minutes morn- 
ing and night will stimulate the intestinal peristalsis and 
help to strengthen the abdominal muscles. The baby is 
old enough to be trained to have a movement at a regular 
hour and to use his muscles in defecation. From four to 
six ounces of water daily between his meals will also be of 
service. 



DISEASES or GASTRO-ENTERIC TRACT. I97 

CASE 52. Robert A., fifteen months old, was the first 
child of healthy parents. He was breast-fed during the first 
year and was not constipated during this time. He was then 
given a mixture of MelHn's Food and milk and became very 
much constipated. After that he was given Imperial Granum, 
and other articles of diet were soon added. When seen he was 
taking milk, oat jelly, bread, orange juice and Bovinine. 
The bowels did not move except with the aid of gluten sup- 
positories. The movements were large, brown or yellow in 
color, coated with mucus, and usually had bright blood on the 
outside. Defecation was very painful. During it the child 
became cold and perspired and stiffened out. Otherwise he 
was well. He sat up but did not creep or try to stand. He 
apparently did not have too large an amount of food. 

Physical Examination. He was good-sized but fat and 
flabby. The muscles seemed poorly developed. His color 
was good. The fontanelle was nearly closed. The tongue was 
clean. He had twelve teeth. There was a slight rosary. 
There was also a slight retraction of the chest at the insertion 
of the diaphragm. The abdomen was not distended and was 
perfectly lax. The liver was palpable i cm. below the costal 
border in the nipple line. The spleen was not palpable. The 
extremities were normal except for a slight enlargement of 
the epiphyses at the wrists. There was no spasm or paralysis. 
The knee-jerks were equal and normal. There was no 
Kernig's sign. There was no enlargement of the peripheral 
lymph nodes. The genitals were normal except that the 
prepuce was rather tight. There was a crack at the edge of 
the anus, both back and front, about one quarter of an inch 
long and one eighth of an inch deep. This crack bled easily 
when the anus was stretched. Rectal examination was 
negative. 

Diagnosis. The diagnosis of constipation is, of course, 
evident. This diagnosis is, however, not sufficient. It is 
necessary to determine the type and the cause of the constipa- 
tion. The pain during defecation and the bright blood on the 
outside of the movement are almost enough of themselves to 
justify the diagnosis of fissure of the anus without physical 
examination. This condition is, of course, proved by the 



1 98 CASE HISTORIES IN PEDIATRICS. 

physical examination. The fissure and the pain caused by it 
are, therefore, the cause of the constipation, and the consti- 
pation is of the spasmodic type. The large size of the move- 
ments suggests some other etiological factor. This suggestion 
is corroborated by the facts that the child does not creep or 
try to stand, and the general flabbiness. That is, the muscular 
development is poor. It is fair to assume that the intestinal 
muscles are also weak and the intestinal peristalsis feeble. 
The constipation is, therefore, partly of the atonic type. 
The cause of the weakness of the muscles is shown by the 
rosary, the retraction of the lower chest and the enlargement of 
the epiphyses at the wrists, all of them manifestations of 
rickets. The final diagnosis is, therefore. Constipation, 
chiefly of the Spasmodic Type; Fissure of the Anus; 
Mild Rickets. An interesting point is that the malt sugar 
in the Mellin's Food, which usually acts as a laxative, had 
the opposite effect in this instance. 

Prognosis. The prognosis is perfectly good with time and 
proper treatment. The fissure should heal in a few weeks 
with very simple treatment. Stretching the sphincter is 
almost never necessary. It will probably take somewhat 
longer to relieve the constipation because, on account of the 
pain in the past, the child will continue to be afraid to have a 
movement even after the fissure is healed, and the atonic 
element will remain after the spasmodic element is relieved. 
The active stage of the rickets, shown chiefly by the weak 
musculature, should yield quickly to treatment. The bony 
signs will persist for many months but will eventually dis- 
appear. 

Treatment. The first object of the treatment is to heal the 
fissure. To do this, it is first necessary to keep the movements 
soft. Until this is accomplished by regulation of the diet, it 
can best be done with an enema of an ounce of sweet oil 
daily. If this is not effectual, he may be given one or two 
teaspoonfuls of milk of magnesia in his milk daily. Local 
cleanliness and the application of boracic acid ointment will 
then quickly heal the fissure. It will almost certainly not be 
necessary to stretch the sphincter. 

A rational routine and diet for him will be as follows: 



DISEASES OF GASTRO-ENTERIC TRACT. 1 99 

6 A.M. Whole milk, 8 ounces. 

9 A.M. Orange juice, 2 tablespoonfuls. 

10 A.M. Oat jelly, 2 or 3 tablespoonfuls. Whole milk, lo 
ounces. 

2 P.M. Mutton or chicken broth, 3 ounces; or beef juice, 
2 tablespoonfuls. Bread or zwiebach, i slice. One-half baked 
apple or 2 tablespoonfuls of prune juice. Whole milk, 4 
ounces, if desired. 

6 P.M. Oat jelly, 2 or 3 tablespoonfuls. Whole milk, 10 
ounces. 

Water should be forced. 

Massage of the abdomen twice daily will stimulate the 
peristalsis and improve the muscular tone. Much fresh air 
and sunlight will help the rickets and general condition, and 
hence the atonic element of the constipation. Tincture of 
nux vomica, in drop doses, three times a day, before meals, 
will also tend to improve the general condition and the intesti- 
nal tone. 



200 CASE HISTORIES IN PEDIATRICS. 

CASE 53. Walter R., eight years old, had always been 
well, except for whooping-cough when three years old. He 
was very constipated until he was four years old, the stools 
being made up of masses of hard ''bullets." These little 
bullets would often slip out into his trousers when he was 
running and playing. During this time he was given enemas 
constantly, many of them being high. Since then the stools 
had been formed, but not hard, the only abnormality about 
them being their large size. He was, however, often unable 
to hold them when playing, although he never dirtied him- 
self when quiet or asleep. His lapses were not due to care- 
lessness, because he always felt very badly about them and 
punishment had made no difference. The attempt had been 
made to prevent these accidents by forcing him to have a 
movement directly after breakfast. He rarely succeeded, 
however, and the straining in the attempt to have a move- 
ment apparently made matters worse, because he almost 
always had an involuntary movement soon after. The fre- 
quency of the accidents varied. Sometimes he went several 
weeks without one; at other times they occurred almost 
every day, while during the previous summer he went sev- 
eral months without trouble. His appetite was good, his diet 
admirable and he had no symptoms of indigestion. He lived 
an ideal out of doors life in the country, was not overstimu- 
lated mentally and showed no signs of nervousness. 

Physical Examination. He was well developed and nour- 
ished and of good color. He seemed of average intelligence 
and not at all nervous. His tongue was clean, his mouth 
and throat normal. The heart and lungs were normal. The 
level of the abdomen was that of the thorax; nothing 
abnormal was detected in it. The liver and spleen were not 
palpable. The genitals were normal. The prepuce was com- 
pletely retractible and there was no local irritation. The ex- 
tremities were normal. There was no spasm or paralysis. 
The knee-jerks were equal and normal. Kernig's and Babin- 
ski's signs were absent. There was no disturbance of the 
sensation. The peripheral lymph nodes were not palpable. 
Rectal examination showed nothing abnormal. The tone 
of the sphincter seemed normal. 



DISEASES OF GASTRO-ENTERIC TRACT. 20I 

Diagnosis. The trouble is, of course, Incontinence of 
Feces. The important question is its cause. It is evidently 
not due, as in some instances, to distention of the rectum 
with hard feces. Judging from his good general condition 
and apparently stable nervous system, it is not due to de- 
bility or lowered nervous tone. There are no signs of local 
irritation. It is probably due, therefore, to delayed develop- 
ment of the normal control of the sphincter ani. It is pos- 
sible, however, that the constipation during the early years 
and the continued use of enemas may have played a part in 
its production by interfering with the normal processes of 
defecation. 

Prognosis. The prognosis is good with time. The condition 
is, however, a disagreeable and annoying one, which should 
be stopped as soon as possible. 

Treatment. There is nothing about his diet or daily rou- 
tine which needs to be changed. There is no indication for 
tonics or nerve stimulants or sedatives, as his general condi- 
tion is good and there is no evidence of any general dis- 
turbance of the nervous system. The treatment must be 
directed toward the development of the control of the sphinc- 
ter muscle. This can best be done by teaching him to con- 
tract and relax the sphincter at will and by practice in doing 
it. There ought not to be much difficulty in teaching him 
to do this, as he is eight years old and of normal intelli- 
gence. It is possible that the application of the faradic cur- 
rent to the sphincter, every other day, may also be of assist- 
ance. 



202 CASE HISTORIES IN PEDIATRICS. 

CASE 54. Louise C, six years old, had complained for 
about a week of itching and burning about the anus, after go- 
ing to bed. Her mother examined her the night before she 
was seen and found what she thought were pin-worms about 
the anus. She had no other symptoms whatever, did not 
pick her nose, was not nervous or irritable, had a good appe- 
tite and digested her food well. 

Physical Examination. She was well developed and nour- 
ished and of good color. Her tongue was clean. The heart, 
lungs, liver, spleen, abdomen and extremities were normal. 
There was no irritation of the vulva or about the anus and 
no enlargement of the inguinal lymph nodes. The things 
which the mother thought were worms were examined and 
found to be really pin-worms. 

Diagnosis. The symptoms in this instance, itching and 
burning about the anus after going to bed, are those most 
characteristic of Pin-worms and should always suggest their 
presence. The next most common symptom is irritation of 
the vulva and vagina. The symptoms usually thought to 
be pathognomonic of pin-worms — picking the nose, nervous- 
ness, irritability and disturbance of the digestion — are usu- 
ally conspicuous by their absence and, if present, are almost 
invariably due to other causes. The diagnosis of pin-worms 
should never be made, however, unless, as in this instance, 
the worms are seen by the physician, because shreds of vege- 
table or fruit fibre are often mistaken for them by mothers 
and nurses. 

Prognosis. It will require several weeks, and probably a 
number of months, of continuous treatment to completely 
eradicate the worms. If the treatment is kept up long enough 
however, it can certainly be done. 

Treatment. The life history of the parasite shows the lines 
along which treatment must be directed. The eggs enter 
through the mouth, and are hatched in the small intestine. 
The worms reach their full development in the large intestine 
and lay their eggs in the rectum. The children get the eggs 
on their fingers, put their fingers in their mouths, and the 
circle is completed. Every precaution must be taken, there- 
fore, to insure strict cleanliness and to prevent reinfection. 



DISEASES OF GASTRO-ENTERIC TRACT. 203 

The next thing to do is to dislodge the worms from the upper 
bowel, wash them down and, if possible, out. She should, 
therefore, be given a tablespoonful of Epsom salts or some 
other saline to clean out the bowels. Salines are better than 
castor oil, because castor oil favors the absorption of san- 
tonin. When the bowels are well emptied, she should be 
kept on broth and toast for twenty-four hours and given 
three doses of one-quarter of a grain each of calomel and 
santonin during the day. This should be followed by another 
dose of Epsom salts. 

It is evident that drugs given by the mouth can do but little 
good after the upper bowel has once been thoroughly cleared 
of the worms, since those that remain are all in the large 
bowel and rectum. They must be reached from below. She 
should, therefore, be given an enema of three ounces of 
sweet oil every night, followed in ten or fifteen minutes by 
an enema of a pint of soapsuds. The worms are caught in 
the oil and are washed out by the suds. These enemata 
must be kept up until no worms are obtained, and then for 
some weeks longer. If they are given up at once, the worms 
will almost certainly appear again in a few weeks. 



204 CASE HISTORIES IN PEDIATRICS. 

CASE 55. Thomas S., five and one-half years old, was the 
child of healthy parents. He had always been well and 
vigorous, except for measles when two and whooping-cough 
when four years old. His appetite had not been very good 
for a year, but he had had no symptoms of indigestion and 
his bowels had moved regularly. He had had no cough, had 
slept well, had been to school regularly and had seemed 
unusually vigorous. He had not picked his nose, been irri- 
table or shown any other signs of nervousness. He had 
passed worms, resembling angle worms, at times for a year, 
but his mother had paid no attention to it, because he seemed 
so well. She showed the last worm to some of her friends, 
however, and they frightened her so much that she brought 
him to the Infants' Hospital. 

Physical Examination. He was well developed and nour- 
ished and of good color. His skin was in good condition. 
His tongue was clean and his nose and throat normal. The 
heart, lungs and abdomen were normal. The liver and spleen 
were not palpable. The extremities were normal. There 
was no spasm or paralysis. The knee-jerks were equal and 
normal. There was a slight general enlargement of the 
peripheral lymph nodes. 

The mother brought in a large round worm which he had 
passed three days before. 

Diagnosis. The worm having been brought in and ex- 
hibited, there can be, of course, no doubt as to the diagnosis 
of Round Worms. It is very noticeable, however, that there 
is nothing whatever in the history to suggest the presence of 
worms, except the fact that he has passed them. This is 
the usual story, and the symptoms ordinarily attributed to 
worms — picking the nose, pain in the abdomen, disturbance 
of the digestion, malnutrition, nervousness, irritability, 
sleeplessness and the like — are, as is ordinarily the case, all 
lacking. He has, in fact, not only shown none of these 
symptoms, but has been unusually well and strong. 

Prognosis. The prognosis is good, as it is usually easy to 
eradicate round worms by the administration of santonin. 
The chances of reinfection are much less than they are with 
pin-worms. 



DISEASES OF GASTRO-ENTERIC TRACT. 205 

Treatment. He should be given a tablespoonful of Epsom 
salts, or some other saline, to clean out the bowels. Salines 
are better than castor oil, because castor oil favors the 
absorption of santonin. When the bowels are well emptied, 
he should be kept on broth, with a little toast, for twenty- 
four hours and given three doses of one-half of a grain each of 
calomel and santonin at four hour intervals. This should be 
followed by one or more doses of Epsom salts. This course 
of treatment will, in all probability, result in the passage of 
all the worms in the intestine. It will be well, however, to 
examine the stools for ova in three or four weeks. If any are 
found, the treatment must be repeated. 



2o6 CASE IN HISTORIES PEDIATRICS. 

CASE 56. Millard R. was admitted to the Children's 
Hospital when four and one-half years old. When two and 
one-half years old he passed a portion of a tape worm, con- 
sisting of 175 segments. He had passed small portions every 
few months since then, and a month before had passed a 
piece, consisting of 150 segments. He had been perfectly 
well, however, in every way. He had had no pain or dis- 
comfort and no disturbance of the digestion. He had not had 
a voracious appetite, had gained steadily in weight and had 
shown none of the nervous symptoms usually attributed to 
worms. 

Physical Examination. He was well developed and nour- 
ished and of good color. His tongue was slightly coated. 
The heart, lungs and abdomen were normal. The liver and 
spleen were not palpable. The extremities were normal. 
There was no spasm or paralysis and the deep reflexes were 
normal. The segments which he brought with him were 
those of the taenia mediocanellata. 

Diagnosis. He unquestionably has a Tape Worm. 

Prognosis. The worm will probably be obtained at the 
first trial, if sufficient care is taken in carrying out the details 
of the treatment. If it is not, the treatment must be repeated 
at intervals until the worm is finally obtained. 

Treatment. It is very important to have the intestines 
emptied of everything but the worm before the anthelmintic 
is administered. The diet for the next two days should be 
made up of foods which have but little residue, such as clear 
soups, whey, white of egg and orange juice, and the amount 
should be limited to that just sufficient to satisfy the pangs of 
hunger. He may also have a little toast. He should be 
given enough of some cathartic, preferably Epsom salts or 
castor oil, to produce several large, loose movements of the 
bowels each day. He should be given a cup of hot beef tea 
or clear broth on waking the morning of the third day. This 
should be followed in one-half an hour by the anthelmintic. 
The best anthelmintic is Tanret's preparation of the tannate 
of pelletierine. The dose for this age is one-third of a bottle, 
which is equal to about one and one-half grains of the drug. 
If this drug is not obtainable, ten minims of the oleoresin of 



DISEASES OF GASTRO-ENTERIC TRACT. 207 

aspidium may be given in its place. He should be given two 
tablespoonfuls of Epsom salts one-half hour later and one 
tablespoonful every subsequent hour until the worm is passed. 
He will be less likely to vomit the anthelmintic and the salts 
if he is kept up and walking about than if he lies still in bed. 
When the worm begins to come he should sit on a vessel filled 
with warm water, because the worm is less likely to break off 
and is more certain to be passed intact if it finds itself in 
comfortable surroundings. It should never be pulled, as it 
is almost certain to break if any force is used. If part of the 
worm remains in the bowel while the rest is out, it can often 
be dislodged by a large enema of warm water. 

Everything which is passed should be saved and carefully 
examined in order to determine whether or not the head has 
been passed, the treatment being of no avail unless this is 
obtained. It is important to remember in this connection 
that the head is dark colored and not much larger than the 
head of a pin and that the upper part of the neck is very thin. 
Unless this is borne in mind, the head is very likely to be 
overlooked and thrown away. 



THE CALCULATION OF FORMULAE FOR THE 
HOME MODIFICATION OF INFANTS' FOODS 
AND THE DETERMINATION OF THEIR COM- 
POSITION AND CALORIC VALUE. 

Many foods have been prescribed in the preceding pages 
but nothing has been said as to how these foods were to be 
prepared. Frequent mention has also been made of the 
content in percentages of fat, sugar, protein and starch of 
various mixtures which the babies were taking and of the 
caloric value of these mixtures, but no data given as to how 
these figures were obtained. As it is necessary for the 
physician to be able to calculate the formulae for milk mix- 
tures and to determine the percentages of the various food 
elements in babies' foods, as well as their caloric value, in 
order to know why they are not thriving on them, it seems 
worth while to describe the methods to be used in these 
calculations. It is necessary in the first place to know the 
composition of the various materials which are used in the 
preparation of infants' foods. 

Whole milk contains approximately fat, 4.00%; milk 
sugar, 4.50%; protein, 3.50%. When milk is allowed to 
set the fat rises to the top, while the sugar and protein re- 
main approximately evenly distributed throughout. This 
is not strictly true, because the higher the percentage of 
fat in a given layer, the lower are the percentages of sugar 
and protein. For practical purposes, however, it is safe 
to consider the percentage of sugar to be 4.50 and that of 
protein 3.20 in the cream or top milk and skimmed milk in 
all mixtures which contain both, as the inaccuracies on the 
two sides about neutralize each other. " Gravity cream," 
which is all the cream which is visible on milk which has set 
six hours or longer, contains about 16.00% of fat. Ordinary 

209 



Top 


ounce contains 






2 


ounces 


mixed contain 




3 










4 










5 










6 










7 










8 










9 










10 










12 










14 










i6 









210 HOME MODIFICATION OF INFANTS FOODS. 

" thick cream," as it is called, contains from 32,00% to 
40.00% of fat. The following table, copied from Chapin and 
Pisek (Diseases of Children, 1919, p. 127), shows the fat 
content of the top sixteen ounces of a quart of milk. 

2 5.o%j fat 
24.0%) „ 
22.5% „ 

21.4% n 
19-2% jy 
16.8% „ 

15-0% '» 

13-3% » 

11.5% » 

10.5% „ 

9.0% „ 

7.8% „ 

7.0% „ 

Skimmed milk, that is, milk from which the cream has 
been removed with a spoon or dipper, contains about 1.50% 
of fat. *^ Fat free '^ milk, or milk from which the cream has 
been removed by centrifugalization contains about 0.25% 
fat. Ordinarily skimmed milk is also considered to be fat 
free, but in disturbances of the digestion of fat the fat in the 
skimmed milk should always be reckoned in. 

Whey contains about 0.25% of fat, 5.00% of milk sugar 
and 0.90% of protein. In routine work, however, the fat is 
disregarded and the sugar reckoned as 4.50%. 

Two rounded tablespoonfuls of milk sugar weigh about an 
ounce, while it takes between three and four level tablespoon- 
fuls to weigh an ounce. For practical purposes all the sugars 
used in feeding babies may be considered to weigh the same. 

Two rounded teaspoonfuls of barley or other flours to the 
pint of water give a 1.50% decoction of starch. With this 
fact as a guide it is easy to determine the percentage of 
starch in any mixture. 

The composition of the various proprietary foods for 
infants can be found in most text books on pediatrics. When 
this is known, the percentages of the various food elements 



CASE HISTORIES IN PEDIATRICS. 2X1 

in the mixtures prepared from them can be determined in 
the same way as when they are made from cream, milk, 
sugar and the cereal waters. 

The Calculation of Formulae for the Home Modification 
of Milk. The following method of calculation, which is the 
one which the author uses in his work, is inaccurate in that 
the fat in the skimmed milk is disregarded and the protein 
is considered to be the same in both the gravity cream and 
skimmed milk. It is, however, simple and the results ob- 
tained are accurate enough for everyday work. It is ad- 
visable, nevertheless, 'to keep the percentage of fat rather 
lower than would be the case, if the food was to be prepared 
at a milk laboratory. 

It is necessary, in the first place, to decide what percent- 
ages of fat, sugar, protein and starch the mixture is to con- 
tain and how much is to be prepared for twenty-four hours. 
It must also be decided whether the food is to contain lime 
water or not. Let us suppose that we wish to prepare 24 
ounces of a food to contain 3.00% of fat, 3.75% of milk 
sugar, 1.20% of protein, 0.75% of starch, and with lime water 
to the amount of 33.00% of the gravity cream and skimmed 
milk. 

The fat in the mixture must be derived from cream or 
" top milk." The author ordinarily uses gravity cream, 
containing 16.00% of fat, as he has found this most conven- 
ient for the mothers. If the food was composed entirely of 
gravity cream it would contain 16.00% of fat. As it is to 
contain but 3.00% of fat, it is evident that only -3^ of the 
mixture will be gravity cream. Three-sixteenths of 24 
ounces is 4I ounces. Four and one-half ounces of gravity 
cream will, therefore, supply the 3.00% of fat desired in the 
mixture. The gravity cream contains 3.20% of protein as 
well as fat. Four and one-half ounces of gravity cream in 
24 ounces will give 4J/24 of 3.20% of protein, or 0.60%. 
It is desired, however, to have 1.20%, or 0.60% more, of 
protein in the mixture. This can be obtained from skimmed 
milk without, according to our assumption, adding any more 
fat. Skimmed milk contains 3.20% of protein. In order 
to get 0.60% of protein in the mixture, it is evident that 



212 HOME MODIFICATION OF INFANTS^ FOODS. 

skimmed milk to the amount of 0.60/3.20 of 24 ounces must 
be added. This is 4^ ounces. 

Both gravity cream and skimmed milk contain 4.50% 
of milk sugar. There are 9 ounces of gravity cream and 
skimmed milk in the 24 ounce mixture. This will furnish 
■^ of 4.50% of milk sugar, or 1.70%. It is desired, however, 
to have 3.75% of sugar in the mixture, i.e., 2.00% more 
than is furnished by the gravity cream and skimmed milk. 
This must be added in the form of dry milk sugar. Two 
per cent of 24 ounces is yfo" of 24 ounces, or half an ounce. 
A rounded tablespoonful of milk sugar weighs J ounce, and 
this amount should, therefore, be added. 

It is also desired to have 0.75% of starch in the mixture. 
This can be added in the form of barley water, containing 
1.50% of starch. To get 0.75% of starch in a 24 ounce 
mixture, using 1.50% barley water, 0.75/1.50 of 24 ounces, 
or 12 ounces, is necessary. 

Lime water to the amount of 33.00% of the milk and cream 
in the mixture is also required. There are 9 ounces of milk 
and cream. Thirty-three per cent of 9 ounces is 3 ounces. 
There being 4I ounces of gravity cream, 4J ounces of skimmed 
milk, 3 ounces of lime water and 12 ounces of barley water 
in the mixture, no water is needed, because these quantities 
exactly make up the amount required. The milk sugar, 
of course, goes into solution and does not increase the quantity 
of the mixture. 

Method for the Calculation of the Percentages in Mixtures. 
The best way to explain this method is to work out the 
composition of a food. Let us suppose that a baby is taking 
a food made up as follows: 

Gravity cream, 10 ounces 

Skimmed milk, 5 ?> 

Lime water, 5 » 

Barley water, 20 >> 

Milk sugar, 4 rounded tablespoonfuls 

The barley water is made by adding two rounded teaspoon- 
fuls of barley flour to the pint. 
The total quantity of this mixture is 40 ounces, as the milk 



CASE HISTORIES IN PEDIATRICS. 213 

sugar goes into solution. The gravity cream contains 16.00% 
of fat. Ten ounces of gravity cream in a 40 ounce mixture 
will give, therefore, i^ of 16.00% of fat, or 4.00% of fat. 
The small amount of fat in the skimmed milk may be dis- 
regarded. The gravity cream and skimmed milk, according 
to our assumption, both contain 3.20% of protein. There 
are 15 ounces of gravity cream and skimmed milk in the 
mixture. The percentage of protein in the mixture will be, 
therefore, H of 3.20%, or 1.20%. According to our calcu- 
lations, the gravity cream and skimmed milk both contain 
4.50% of milk sugar. The 15 ounces of gravity cream 
and skimmed milk in the 40 ounce mixture will give, 
therefore, ^o of 4-5o%> or nearly 1.70% of milk sugar in 
the mixture. More sugar has been added, however, in the 
form of dry sugar. The 4 rounded tablespoonfuls of milk 
sugar which have been added are equal to 2 ounces. Two 
ounces in a 40 ounce mixture will give -^ of 100.00% of 
sugar, or 5.00%. The sum of 1.70% and 5.00% is 6.70%, 
which is the percentage of milk sugar in the mixture. The 
barley water, which is made by adding barley flour to water 
in the proportion of 2 rounded teaspoonfuls to the pint, 
contains 1.50% of starch. Twenty ounces of barley water 
of this strength in a 40 ounce mixture gives |-§- of 1.50% of 
starch, or 0.75% of starch, in the mixture. The 5 ounces of 
lime water is |, or 33.00% of the 15 ounces of gravity cream 
and skimmed milk in the mixture. The composition of this 
food is, therefore, approximately: 



Fat, 


4-oo% 


Milk sugar. 


6.70% 


Protein, 


1.20%, 


Starch, 


0.75% 


Lime water. 


33.00% of the cream and milk 



Method for the Calculation of the Caloric Value of Mix- 
tures. There are a number of satisfactory methods for the 
determination of the caloric value of infants' foods. The 
following method, which is a little longer than some of the 
others, is, however, accurate and has this advantage, that 
it is impossible to do it without understanding just what the 



314 HOME MODIFICATION OF INFANTS' FOODS. 

caloric value of food means. Here again the best way to 
explain the method is by calculating the value of a food. 

Let us suppose that a baby is taking six feedings of five 
ounces of a food containing 3.00% of fat, 6.00% of sugar, 
1.25% of protein and 0.75% of starch. One ounce is very 
nearly 30 cubic centimeters. Thirty ounces is equal, there- 
fore, to 900 cubic centimeters. Three per cent of fat means 
that there are 3 grams of fat in each 100 cubic centimeters 
of food. If there are 3 grams of fat in 100 cubic centimeters, 
there must be 9 times 3 grams, or 27 grams, in the 900 cubic 
centimeters which the baby is taking. The caloric value of 
one gram of fat is 9.3 calories. The caloric value of 27 
grams of fat is 27 times 9.3 calories, or 251.1 calories. The 
caloric value of sugar, starch and protein is almost exactly 
the same, a gram of each furnishing 4.1 calories. The 
caloric value of these elements can, therefore, be calculated 
at the same time. There are 6 grams of sugar, 1.25 grams 
of protein and 0.75 grams of starch in each 100 cubic centi- 
meters of food, or a total of 8 grams in each 100 cubic centi- 
meters. In 900 cubic centimeters there are, of course, 9 
times 8 grams, or 72 grams. If one gram of sugar, starch 
and protein equals 4.1 calories, the caloric value of 72 grams 
must be 72 times 4.1 calories, or 295.2 calories. The sum 
of the 2 5 1. 1 calories furnished by the fat in the mixture and 
of the 295.2 calories furnished by the sugar, starch and protein 
is 546.3 calories, which is the caloric value of the mixture. 

Another more rapid, but less accurate, method of cal- 
culating the caloric value of infants' foods is that recom- 
mended by Fraley (Archives of Pediatrics, 191 2, xxix, 123). 
In this method F = the percentage of fat, 5 = the per- 
centage of sugar and starch, P= the percentage of pro- 
tein and Q = the total quantity of the mixture. According 
to his formula 

2F + P + S X ijQ (in ounces) = calories. 
Calculating this same mixture in this way 

6.00 + 1.25 -f 6.75 X 37.5 = 525 calories. 

The caloric value obtained by this method is always some- 
what lower than that obtained by the first method, the 
difference in this instance being a little more than 21 calorie*. 



SECTION IV. 
DISEASES OF NUTRITION. 

CASE 57. Cynthia M., the first child of healthy parents, 
was born at full term after a normal labor, and weighed 
ten and one-fourth pounds. The breast-milk gave out after 
two weeks and she was put on a rather strong modification 
of milk, on which, nevertheless, she did fairly well. She 
began to vomit when two months old and the gain in weight 
became very slow, but the movements remained normal. 
When four months old she was put on a home modified milk 
which contained about 2% of fat, 9.60% of sugar, 0.75% of 
whey proteids and 0.40% of casein. She had seven feedings 
of six ounces. She vomited less while taking this mixture, 
but continued to regurgitate. She had one normal move- 
ment daily, but her weight remained stationary. She had 
some colic. The sugar in the mixture was reduced to 6% 
and the vomiting and colic became less. When five months 
old, as she did not gain, she was changed to a home modified 
mixture which contained about 1.80% of fat, 1.10% of sugar, 
0.90% of proteids and 0.50% of starch. She took seven feed- 
ings of six ounces. She was not at all satisfied, vomited less 
than before and had very little colic, but was somewhat 
constipated. The movements were normal in character. 
She held her weight the first week, but lost half a pound the 
second week. She was then seen, when six months old. She 
slept well, had plenty of fresh air and did not act sick. 

Physical Examination. She was fairly developed and 
nourished. Her color was good. She was a little flabby. 
The fontanelle was level. The mouth was healthy and the 
tongue clean. She had one tooth. There was a very slight 
rosary. The heart and lungs were normal. The level of the 
abdomen was that of the thorax, and nothing abnormal was 
detected in it. The liver was palpable i cm. below the costal 

215 



2l6 CASE HISTORIES IN PEDIATRICS. 

border in the nipple line. The spleen was not palpable. 
The extremities were normal. There was no spasm or paraly- 
sis; the knee-jerks were equal and normal; Kernig's sign was 
absent. There was no enlargement of the peripheral lymph 
nodes. She weighed thirteen pounds. 

The movement was yellow and salve-like in consistency, 
except in one place where it was a little granular and brittle. 
The odor was slight. The reaction was alkaline (presumably 
from the relatively large amount of proteid in relation to the 
fat). Microscopically it showed no undigested fat or starch, 
and there were no casein curds. 

Diagnosis. The physical examination shows nothing ab- 
normal except flabbiness and a slight rosary. The former is, 
of course, merely a sign of malnutrition. The rosary means 
rickets, but when it is slight and the only bony sign of the 
disease, as in this instance, the rickets is of practically no 
importance and need not be considered. The very slight 
amount of the vomiting and the normal movements show that 
there can be no disturbance of digestion sufficient to account 
for the loss of weight. The evident hunger and the tendency 
to constipation point strongly to an insufficient supply of 
food as the cause. Whether this is so or not can, of course, 
be determined practically by giving more food and awaiting 
the result. Proceeding in this way, however, there is no guide 
as to how much more food should be given. It is far better 
to calculate the caloric value of the food and thus know the 
truth at once, and, if the baby is under-fed, know how much 
so, and also how much more food to give. 

A baby of six months requires, on the average, about lOO 
calories per kilo daily in order to thrive and gain. This baby 
weighs 5.9 kilos and, therefore, needs about 600 calories 
daily. It is not a difficult matter to calculate the caloric 
value of the food. Forty- two ounces equals 1,260 ccm.; 
1.8% of fat equals 1.8 grams of fat in 100 ccm. of food, or 22.6 
grams in 1,260 ccm. The caloric value of I gram of fat is 
9.3 calories. The caloric value of the fat in the food is, there- 
fore, 210 calories. The caloric value of proteid, sugar and 
starch being the same, 4.1 calories per gram, they can be 
calculated together. Figuring in the same way as for the fat, 



DISEASES OF NUTRITION. 21 7 

they together furnish 129 calories. The total value of the 
food is, then, 339 calories or 57 calories per kilo, only a little 
more than half the caloric needs. 

A baby must not only get a certain number of calories 
daily in its food, but it must also get at least 1.5 grams of 
proteid per kilo in order to thrive. It will gradually fail and 
die if the proteids are insufficient, even if the food contains a 
sufficient number of calories. This baby's food contained 
0.9% of proteid or 11. 3 grams in the 42 ounces. This is equal 
to 1.9 grams of proteid per kilo and amply covers the proteid 
needs. This ample supply of proteids explains her good 
general condition and the fact that she has not appeared 
sick. 

The diagnosis is, therefore. Malnutrition from an In- 
sufficient Supply of Food. The knowledge that the caloric 
value of the food is insufficient also enables us to rule out 
any serious disturbance of metabolism in which there is a 
progressive loss of weight, while the caloric value of the food 
is normal and there are no symptoms of indigestion. 

Prognosis. The prognosis is, of course, perfectly good if 
the caloric value of the food is increased. There seems to be 
no reason why it cannot be in this instance as the stools show 
that all the components of the food are digested. 

Treatment. The best food for infants, whether sick or well, 
is human milk. A wet nurse is, therefore, the best treatment 
for this patient. A wet nurse is not necessary in this instance, 
however, as the baby can undoubtedly be easily fed on some 
modification of cow's milk. 

Past experience shows that it will not be wise to give this 
baby over six per cent of sugar. It is advisable to keep the fat 
down when babies vomit. It will, therefore, be wise to keep 
the percentage of fat as low as is consistent with meeting the 
caloric needs. There is no objection to giving a reasonably 
high percentage of proteids, as the baby has already shown 
her ability to digest them. It will be wise to continue the 
starch in the mixture, since the examination of the stools 
shows that the baby can digest it and it adds to the caloric 
value of the food. Six feedings of five and one-half ounces 
each ought to be about right for her age and weight. 



2l5 CASE HISTORIES IN PEDIATRICS. 

The following formula meets these indications and covers 
both the caloric and proteid needs: 

Fat, 2.50% 

Sugar, 6.00% 

. Proteids, 1.50% 

Starch, 0.75% 

Six feedings of 5J ounces give 565 calories, or 96 calories 
per kilo, and 14.8 grams of proteid, or 2.5 grams of proteid per 
kilo. 

Approximately the same mixture can be prepared at home 
as follows: 

Gravity cream (16%), 5 ounces 
Skimmed milk, 10 ounces 

Barley water (1.50% 

starch), 18 ounces 

Milk sugar, 2 rounded and I level 

tablespoonful 

Two teaspoonfuls of barley flour to a pint of water makes a 
1.50% starch solution. One rounded tablespoonful of milk 
sugar is equal to about half an ounce. 

No drugs are indicated. 



DISEASES OF NUTRITION. 2ig 

CASE 58. David W., was bom at full term and was the 
only child of healthy parents. There was no history of tuber- 
culosis In the family and no known exposure to it. He weighed 
nine pounds at birth, but fell to six pounds in the first three 
weeks, and w^hen seen in consultation at eleven months 
weighed but ten pounds. He had always been fed on milk, 
prepared in various ways. During the first month the mixture 
had been sterilized. This apparently upset the baby and 
caused considerable constipation. A little later he was given 
one part of whole milk to three of water, but as the move- 
ments contained curds, the strength was reduced to one part 
of whole milk to six of water. As he still passed curds, he 
was given a condensed milk mixture, containing one part of 
condensed milk to twelve of water. As he did not gain and 
continued to have curds in the stools, he was given a modified 
milk mixture prepared at a laboratory. He was at first given 
straight proteids of one per cent; later, part of the proteids 
were given in the form of whey proteids. He did better on 
this, but the movements still contained curds. This was 
stopped after a few months and he was put on condensed 
milk again. As he did not gain, he was put back on modified 
milk. During the last month he had been taking six feedings 
of 5I ounces of a mixture containing 2.75% of fat, 6.00% of 
sugar and 0.25% of proteids, but was not gaining. 

He had been constipated during all this time, except for 
two short attacks of diarrhea a month or two before he was 
seen. He had always taken his food well and had almost 
never vomited. The movements had always been fairly well 
digested, except that they at times contained a few curds. 
He was a quiet baby and almost never fussed. 

Physical Examination. He was small and poorly nourished. 
Pallor was marked. The skin was somewhat dry. The 
anterior fontanelle was 2 cm. in diameter, the level being 
somewhat below that of the surrounding bones. He had two 
lower incisors. There was no rosary. The heart and lungs 
were normal. The level of the abdomen was below that of 
the thorax; it was lax, easily palpable and showed nothing 
abnormal. The liver was palpable 2 cm. below the costal 
border in the nipple line; the spleen was not palpable. The 



^20 CASE HISTORIES IN PEDIATRICS. 

extremities showed nothing abnormal. There was no spasm 
or paralysis; the knee-jerks were equal and normal. There 
was a slight general enlargement of the superficial lymph 
nodes. The weight was ten and one-half pounds. 

Diagnosis. The examination shows nothing except mal- 
nutrition. It gives no clue as to its cause. This must be 
sought in the history. In general, the causes of malnutrition 
which give no physical signs beyond those of malnutrition 
are congenital syphilis, chronic diffuse tuberculosis, " in- 
fantile atrophy/' chronic indigestion and starvation. 

Disturbance of nutrition is the main symptom in some 
cases of congenital syphilis. The good family history, the 
absence of any other signs of syphilis and the presence of 
other causes for the malnutrition rule it out in this instance. 
The slight general enlargement of the superficial lymph nodes 
does not point either to syphilis or tuberculosis. It is com- 
mon to all disturbances of nutrition in infancy and is, conse- 
quently, of no diagnostic value. Chronic diffuse tuberculosis, 
meaning by this term the condition in which there are 
numerous tubercular foci scattered throughout the body, 
larger and older than the miliary tubercle, but not large enough 
or so situated as to give physical signs, is not very infre- 
quent in infancy. It cannot be recognized on physical exam- 
ination, but only by the tuberculin test. It cannot be ruled 
out in this instance, but is less probable than some other 
conditions. The symptoms of indigestion are not suffi- 
cient to account for the malnutrition. 

Barring chronic diffuse tuberculosis, which can only be 
positively excluded by a tuberculin test, the diagnosis lies, 
therefore, between " infantile atrophy " and starvation. The 
term, *' infantile atrophy,'* should be limited to those cases 
in which there is a progressive loss of weight in spite of a 
sufficient intake of food, there being at the same time no 
symptoms of disturbance of the digestion. In this class of 
cases there is presumably some obscure disturbance of absorp- 
tion or metabolism. Clinically they form a very definite 
group. It is probable, however, that, with the increase of our 
knowledge of chemical pathology, they will, in the future, be 
classified in some other way. 



DISEASES OE NUTRITION. 221 

While he was taking the condensed milk and whole milk 
mixtures he was unquestionably not getting enough calories, 
but in the last mixture he got 105 calories per kilo, or just 
about enough to cover his caloric needs. A baby cannot 
thrive, however, even if the food contains a sufficient number 
of calories, if it does not also contain proteids enough to 
cover the proteid needs. The condensed milk and whole 
milk mixtures contained, respectively, 0.66%, 0.87% and 
o-5o% of proteids, which were probably not quite enough to 
meet the proteid needs. His last mixture gave but 0.5 
grams of proteid per kilo, while he needed at least 1.5 grams 
of proteid per kilo. The diagnosis of " infantile atrophy " is, 
therefore, not justified because, while he is getting a sufficient 
number of calories, he is not getting enough proteid, and the 
condition is best called Malnutrition from an Insufficient 
Amount of Proteid in the Food. 

Prognosis. The prognosis must be held in abeyance until 
the effect of an increase in the proteids is known. If he begins 
to gain when they are increased, the prognosis is good; if he 
does not, it is very grave unless he is given human milk. If 
he gets this he will probably recover, because babies can 
usually utilize the proteids of human milk even if they cannot 
those of cow's milk. 

Treatment. The treatment consists in the regulation of 
the food. Human milk is altogether the best food for him. 
It will almost certainly cure him. If he cannot get this, the 
next best thing is some modification of cow's milk. He is 
digesting the present mixture, which, however, does not con- 
tain enough proteid. The natural thing to do, therefore, is 
to leave the percentages of fat and sugar unchanged and to 
increase the proteids to 0.75% in order to cover his proteid 
needs, keeping the number and amount of the feedings the 
same. There is no indication for medicinal treatment 



222 CASE HISTORIES IN PEDIATRICS. 

CASE 59. Helen S. was the second child of healthy 
parents. She was born January i, at full term, after a normal 
labor, was normal at birth and weighed six and one-quarter 
pounds. She had never had anything but the breast and 
had done well in every way up to May 21, when she weighed 
thirteen pounds and four ounces. She had appeared per- 
fectly well since then, but had not gained any in weight. 
She had formerly nursed for twenty minutes, but recently 
had nursed well for only four or five minutes, after which she 
would not try any more, although her mother felt very 
confident that the breasts were not emptied. She seemed 
satisfied and did not appear hungry before the next feeding 
time. She was nursed six times in the twenty-four hours. 
She did not vomit. The bowels moved daily without assist- 
ance, but the stools were small and hard. Her mother was 
well. She was taking about three pints of milk, cocoa and 
soup daily, as well as a little malt, and was gaining rapidly in 
weight. She thought, however, that, in spite of the extra 
liquid and malt, the amount of milk was somewhat less than 
it was a month before. The baby was seen June 6, when a 
little more than five months old. 

Physical Examination. She was well developed and nour- 
ished and of good color. The anterior fontanelle was three 
cm. in diameter and level. The mouth and throat were 
normal. She had two teeth. There was no rosary. The 
heart, lungs and abdomen were normal. The lower border 
of the liver was palpable two cm. below the costal border in the 
nipple line. The spleen was not palpable. The extremities 
were normal. There was no spasm or paralysis. The knee- 
jerks were equal and normal. There was no enlargement 
of the peripheral lymph nodes. She weighed thirteen and 
one-quarter pounds. 

Diagnosis. The failure to gain in weight and the slight 
constipation, in the absence of all symptoms of illness, point 
strongly to an insufficient amount of food. So does also 
the voluntary shortening of the time of nursing, it being a 
very common thing for babies to stop nursing after they have 
satisfied the pangs of hunger, if the supply of milk is insuffi- 
cient and it is very hard work to get it. The fact that she 



DISEASES OF NUTRITION. 223 

docs not appear hungry before the next feeding is not in- 
consistent with this explanation, because it is not very un- 
common for babies not to appear hungry, even when the supply 
of milk is insufficient for them to gain on, if they are getting 
enough to cover their actual needs and to keep their weight 
stationary. The fact that her mother thinks there is still milk 
in the breast after she has stopped nursing is of no impor- 
tance, because it is impossible for a woman to know whether 
there is milk in the breast or not, unless it is very full. 

The trouble with the milk may be in the quantity, the 
quality or both. The only way to find out how much milk 
the baby is getting is to weigh it before and after every 
nursing for several days. It is not necessary to undress the 
baby to do this. The increase in weight will show, of course, 
how much milk has been taken. If the baby will not keep 
still, the mother can weigh herself before and after nursing. 
Her loss represents, of course, the baby's gain. The absence 
of all symptoms of indigestion and the failure to gain in 
weight show that the failure to nurse well is not because the 
milk is too rich as a whole, while the absence of symptoms of 
indigestion proves that there is no excess of any individual 
element. If there is any trouble with the quality of the milk, 
it must be, therefore, that it is weak as a whole or in some one 
of its constituents. The only way to find out whether it is 
or not, is to analyze it. 

The baby was weighed before and after nursing for several 
days and found to be getting about three ounces at a feeding, 
or an average of eighteen ounces a day. The analysis of the 
milk showed that it contained 1.09% of fat, 6.50% of sugar 
and 1.91% of proteids. That is, she was getting only about 
one-half as much milk as she should and this milk was 
markedly deficient in fat. Eighteen ounces of this milk 
contained about 240 calories, which gave her only about 40 
calories per kilo, or less than half enough to cover her 
caloric needs. The diagnosis of Malnutrition from an 
Insufficient Amount of Food, which was made on the 
symptomatology, is, therefore, verified. 

Prognosis. The mother is well; she is taking a sufficient 
amount of extra liquids and has been nursing for five months. 



224 CASE HISTORIES IN PEDIATRICS. 

It is very improbable, therefore, that the amount of milk can 
be increased again or that the percentage of fat can be made 
higher. The baby is in good condition and her digestion is 
normal. She can be confidently expected, therefore, to thrive 
and gain when enough modified cows^ milk is added to her 
diet to cover her caloric needs. 

Treatment. It is useless to attempt to increase the amount 
of the breast-milk by giving more liquids, because more than 
three pints of extra liquid in the twenty-four hours, instead 
of increasing the amount of milk, almost invariably either 
upsets the mother's digestion or makes her grow fat. If the 
mother was not well or was underfed, it might be possible 
to increase the percentage of fat in her milk by giving her a 
more liberal and nutritious diet. She is, however, both 
healthy and well fed. Nothing can be done, therefore, to 
increase the percentage of fat in the milk. The liquids 
which are most useful in increasing the supply of milk are 
gruels; next to them, milk and cocoa. Preparations of 
malt have no especial value, and are likely to disturb the 
digestion of both mother and child. There are no drugs 
which have any action in increasing the supply of milk. 
The best way to increase or to keep up the supply of milk 
is to empty the breasts thoroughly at regular intervals. 
The baby should, therefore, be given both breasts at each 
nursing, the intervals and number of nursings being kept as 
they are at present. She should be weighed before and after 
nursing from time to time in order to determine about how 
much she is getting. She should then be given enough 
modified cows' milk after the breast to bring the amount 
at each feeding up to six ounces. The modified milk should 
contain a high percentage of fat to make up for the deficiency 
of fat in the breast-milk. A mixture containing 4% of fat, 
7% of milk sugar and 1.75% of proteids will be a suitable 
one. There is no indication for the addition of an alkali. 
Eighteen ounces of this mixture, which, judging from the 
amount of breast-milk she has been taking, is about the 
amount which will be necessary to bring up the amount at 
each feeding to 6 ounces, contains nearly 400 calories. This 
will amply cover her caloric needs. 



^ . 

^^'^J 




Case 60. 
George T., Rachitic head. John S., Hydrocephalic head. 




Curve of weakness. Case 60. 



DISEASES OF NUTRITION. 22$ 

CASE 60. Almira R. was admitted to the Children's 
Hospital when thirteen months old. Her parents, who were 
Italians, were well, as were two older children. There had 
been no deaths or miscarriages. Her mother, who brought 
her to the hospital, could speak but little English and on this 
account but little could be learned about her. She was 
nursed entirely for five months, after which she was given 
food from the table in addition. She had recently been 
taking condensed milk, eggs, rice, macaroni, and probably 
many other things also, during the day and been given the 
breast at frequent intervals all night. She had been sick 
ever since she had begun to take other food in addition to 
the breast-milk. She had vomited every two or three days 
and had had several undigested stools daily. She had had 
a little cough recently, but her mother did not know whether 
she had been feverish or not. 

Physical Examination. She was poorly developed and 
nourished and moderately pale. She was feeble, but noticed 
what was going on about her. The parietal and frontal emi- 
nences were somewhat enlarged and the top of the head 
flattened. There was no craniotabes. The anterior fonta- 
nelle was four cm. in diameter and slightly depressed. The 
tongue was covered with a moist, white coat. She had eight 
teeth. The area of the cardiac dullness could not be deter- 
mined, because of the deformity of the chest. The sounds 
were normal and apparently in the normal position. There 
were no murmurs. There was a very marked rosary and a 
large depression on both sides of the chest, into which the 
flexed arms fitted. The sternum was prominent. There was 
marked flaring of the lower ribs. She was unable to sit 
alone and there was a marked curve of weakness. Both 
sides of the chest moved alike. There was moderate retrac- 
tion of the lower ribs on inspiration. There w^as a small area 
of dullness at the angle of the scapula on the right and an- 
other small patch, at the level of the angle of the scapula, in 
the left posterior axillary line. Respiration in these areas 
was bronchovesicular. Fine and medium moist rMes were 
heard all over the chest, both back and front. The abdo- 
men was protuberant, soft and tympanitic. There was no 



226 CASE HISTORIES IN PEDIATRICS. 

tenderness and no masses were felt. The upper border of the 
liver flatness was at the upper border of the sixth xib in the 
nipple line; the lower border was palpable four cm. below 
the costal border in the same line. The spleen was not pal- 
pable. There was moderate bowing of the lower legs and 
marked enlargement of the epiphyses at the wrists and 
ankles. There was no spasm or paralysis. The knee-jerks 
were equal and normal. There was a moderate general en- 
largement of the peripheral lymph nodes. The rectal tem- 
perature was 99° F.; the pulse, 120; the respiration, 35. 
She weighed fourteen pounds. 
, The leucocytes numbered 22,400. 

The sputum contained no tubercle bacilli. 

Diagnosis. The enlargement of the parietal and frontal 
eminences, the widely open fontanelle, the marked rosary, 
the deformity of the chest, the enlargement of the epiphyses 
at the wrists and ankles and the bowing of the legs justify 
the diagnosis of a high grade of Rickets. The deformity of 
the chest is undoubtedly also due in part to the Italian 
method of swathing their babies. The disturbance of the 
nutrition due to the improper feeding is without question 
the chief cause of the rickets, although it is probable that 
improper hygienic surroundings and lack of fresh air and 
sunlight also played a part in its production. The rales and 
the two areas of dullness and bronchovesicular respiration 
show that there is an accumulation of liquid in the bronchi 
and partial solidification of the lungs. The absence of 
tubercle bacilli in the sputum shows that the trouble is not 
tubercular. Do these signs show that there is a bronchitis 
and bronchopneumonia or are they merely the manifesta- 
tions of the retention of the bronchial secretions and atelec- 
tasis of the lungs as the result of the deformity and defective 
expansion of the chest? The physical signs are consistent 
with either condition, as is the increase in the rate of the 
respiration. The diagnosis must be made, therefore, in some 
other way. The leucocytosis seems, at first thought, to count 
strongly in favor of bronchitis and bronchopneumonia. It 
becomes of less importance, however, when the frequency of 
leucocytosis in disturbances of nutrition, associated with 



DISEASES OF NUTRITION. 227 

anemia and rickets, is remembered. The normal tempera- 
ture and pulse rate, on the other hand, are inconsistent with 
bronchitis and bronchopneumonia and are sufficient to rule 
it out. The diagnosis of Atelectasis of the Lungs and 
retained secretions from defective expansion of the chest is, 
therefore, justified. 

Prognosis. The disturbance of the digestion has lasted 
so long, her general condition is so poor, the deformity of the 
chest is so marked and it interferes so much with the expan- 
sion of the lungs that the chances are very much against her 
recovery. She probably will not live more than a few weeks. 
If she recovers, the improvement will be very slow and she 
will almost certainly be left with a misshapen chest. 

Treatment. The treatment consists principally of regu- 
lation of her surroundings and her diet. She must be given 
the greatest possible amount of fresh air and sunlight. The 
best food for her is human milk, even if she is thirteen months 
old. Her mother's milk is insufficient in quantity and prob- 
ably poor in quality. She ought, therefore, to have a wet 
nurse. If this is not feasible, the best substitute is some 
form of modified cows' milk. A mixture containing 3% of 
fat, 6% of milk sugar, 1.50% of proteids and 0.75% of starch, 
with lime water 20% of the milk and cream in the mixture, 
will be a suitable one. Seven feedings of six ounces at three- 
hour intervals should be sufficient for the present. Strych- 
nia, in doses of j^q of a grain, every four hours, will stimu- 
late the respiration and improve her general condition. 



2 28 CASE HISTORIES IN PEDIATRICS. 

CASE 6i. George T. was the oiily child of healthy par- 
ents. He was born two months before he was expected. He 
had never been nursed, but had been fed on whole cow's milkj^ 
more or less diluted with water. He had never done well. 
He vomited at times directly after feeding, but never between 
feedings. His bowels were constipated ; the movements were 
smooth. His head sweat a great deal. He was fussy and slept 
poorly. He was brought to the hospital when eleven months 
old. 

Physical Examination. He was small and thin, weighing 
but nine pounds. Pallor was marked. He could hold up his 
head, but was unable to sit alone. When supported he sat 
with a marked general kyphosis. This disappeared when he 
lay on his face. The frontal and parietal eminences were so 
much enlarged that the top of the head showed a depression 
between them both longitudinally and across. The anterior 
fontanelle was 5 cm. in diameter and depressed. There was 
no craniotabes. The pupils were equal and reacted to light. 
There were no teeth. The mouth and throat were normal. 
There was a marked rosary and there was a depression around 
the lower part of the chest at the level of the insertion of the 
diaphragm, with moderate flaring of the ribs below. The 
heart and lungs were normal. The liver was palpable 3 cm. 
below the costal border in the nipple line ; the spleen was not 
palpable. The extremities showed nothing abnormal except 
a moderate enlargement of the epiphyses at the wrists and 
ankles. There was no spasm or paralysis; the knee-jerks 
were equal and normal. There was a moderate general en- 
largement of the peripheral lymph nodes. There was no 
eruption. 

The urine was pale, slightly acid, of a specific gravity of 
1,010 and contained no albumin. 



Blood. 




Hemoglobin, 


25% 


Red corpuscles. 


2,566,000 


White corpuscles, 


15,000 


Small mononuclears, 


62% 


Large mononuclears, 


3% 


Polynuclear neutrophiles, 


34% 


Eosinophiles, 


1% 



DISEASES OF NUTRITION. :229 

There was moderate variation in the size, but none in the 
shape or staining reaction, of the red corpuscles. No nucle- 
ated forms were seen. 

Diagnosis. The diagnosis is, of course. Rickets and 
Secondary Anemia. The enlargement of the frontal and 
parietal eminences with the resultant "square" head, the 
rosary and the enlargement of the epiphyses at the wrists and 
ankles are pathognomonic of rickets. The weakness of the 
back, the large anterior fontanelle, the absence of teeth and 
the deformity of the chest are, in this instance, undoubtedly 
also signs of rickets, but are not pathognomonic, as they may 
be caused by other conditions. 

The rachitic enlargement of the head, so well shown in this 
baby, is not infrequently mistaken for hydrocephalus. There 
should not, however, be any difficulty in distinguishing be- 
tween them. The enlargement of the rachitic head is due to 
the overgrowth of bone on the outside ; that of the hydroceph- 
alic head, to increased pressure on the inside. The rachitic 
head is asymmetrical and flattened on top; the hydrocephalic, 
symmetrical and rounded. In the former the fontanelle is 
level or sunken; in the latter, bulging. In rickets the eyes 
appear normal ; in hydrocephalus, they are prominent. These 
differences are well shown in the accompanying photographs. 

The kyphosis seen in this instance is often mistaken for the 
deformity of Pott's disease. The diagnosis between them is, 
however, a simple one. The deformity in rickets is due to 
muscular weakness, is a general rounded curve, involving the 
whole spine, and disappears on extension. That in Pott's 
disease is due to deformity of the bone, is a local angular 
protuberance, involving only part of the spine, and does not 
disappear on extension. 

The blood picture is that of a secondary anemia of a moder- 
ate grade. The percentage of hemoglobin is relatively lower 
than the number of red corpuscles. This '^chlorotic" type 
of blood is characteristic of the secondary anemias of infancy. 
The white count is so little above the normal that it can hardly 
be called a leucocytosis, especially as the differential count of 
the white cells is normal for this age. The anemia should not 
be regarded as a symptom of the rickets, but merely as 



23© CASE HISTORIES IN PEDIATRICS. 

another manifestation of the same disturbance of nutrition 
which caused the rickets. The fact that he was born pre- 
maturely probably predisposed him to the development of 
anemia, because premature infants have, as a rule, a smaller 
reserve supply of iron in the liver than those born at full term. 

Prognosis. The prognosis as to life is good. The activity 
of the rachitic process will quickly cease under proper treat- 
ment, but the bony deformities will still remain. The rosary 
and enlargement of the epiphyses will disappear in a year or 
two. The deformity of the chest will probably never entirely 
disappear, and his head will probably always be a little large 
and peculiarly shaped, but not enough so to attract any 
attention. 

Treatment. The treatment is hygienic and dietetic, not 
medicinal. He should be given the maximum amount of 
fresh air and sunlight and should be especially protected 
against all sorts of contagion. 

Breast milk is undoubtedly the best food for him, although 
he is eleven months old. In all probability, however, he 
will not take the breast. The milk can be obtained, never- 
theless, with a pump and fed to him in a bottle. Even a 
little human milk will help him to utilize modified cows' milk. 

There are no special indications as to what proportion of 
modified milk will best suit him, except that he has not done 
well on the combination of low fat and sugar with high pro- 
teids, which he has had in the past. A reasonable mixture 
for him is: 

Fat, 3.50% 

Sugar, 7-00% 

Proteids, 1.50% 

Starch, 0.75% 

An alkali is not indicated in this instance as there has been 
no disturbance of the protein digestion. Six feedings of six 
ounces are sufficient for his weight. If the constipation con- 
tinues on this mixture, he may have from one-half to two 
tablespoonfuls of orange juice daily. If this does not relieve 
the constipation, he may have from one-half to two tea- 
spoonfuls daily of the milk of magnesia. 



DISEASES OF NUTRITION. 23 1 

The saccharated oxide of iron in three-grain doses, or 
ferratin in two-grain doses, will help the anemia. The author 
has not seen any better results when cod-liver oil and phos- 
phorus have been given in addition to regulation of the diet 
and hygienic surroundings than when they have not, and 
consequently seldom prescribes them. 



232 CASE HISTORIES IN PEDIATRICS. 

CASE 62. Dorothy C. was the only child of healthy 
parents. There had been one miscarriage subsequent to her 
birth. There was no tuberculosis in the family and she had 
had no known exposure to it. She was born at full term, 
after a normal labor, and weighed seven and one-half pounds. 
She was fed from the first on modified cows' milk and did 
well, except for some eczema on the face between the fifth 
and eighth months, until she was a year old, when she had 
an attack of infectious diarrhea. She was then well until 
she was two years old, since when she had had, three or four 
times each year, an attack of diarrhea, accompanied by dis- 
tention of the abdomen and much loss of weight, lasting from 
three to five weeks. In these attacks she had from six to ten 
shiny, loose, green, foul movements daily. Four months 
before she was seen, she had a very severe attack of diarrhea 
from which she had not rallied, although the diarrhea ceased 
after the usual period. She was weak and had frequent, 
slight, dull headaches. She had become markedly pale. Her 
appetite was poor. She had no nausea or vomiting. Her 
bowels moved once or twice daily, the movements usually 
being more or less undigested, but sometimes constipated. 
Knock-knees had been noticed for a year and one-half. Her 
physician was sure, however, that she had shown no signs of 
rickets before she was five years old. She was seen in con- 
sultation, when seven and one-half years old. 

Physical Examination. She was fairly developed and 
poorly nourished. Pallor was marked. She was intelligent, 
but listless. Her head was of normal size and shape. Her 
tongue was slightly coated, her teeth good, her throat normal. 
There was a venous hum in the neck. There was a moderate 
rosary and some flaring of the lower chest. There was also 
slight scoliosis. The lungs were normal. The heart was 
normal, except for a slight systolic murmur at both base and 
apex. When she stood, the whole abdomen was protuberant, 
the enlargement being most marked in the lower half. When 
she lay down, the level of the abdomen was that of the 
thorax. The upper half was tympanitic, the lower half mod- 
erately dull. There was dullness in the flanks, which changed 
slightly with change of position. There was no fluid wave. 



DISEASES OF NUTRITION. 233 

There was no muscular spasm or tenderness, and no masses 
were felt. The upper border of the liver flatness was at 
the sixth rib in the nipple line. The lower border was felt 
just below the costal border in the same line. The upper 
border of the splenic dullness was at the eighth rib. The 
spleen was palpable three and one-half cm. below the costal 
margin. There was marked knock-knees and marked en- 
largement of the epiphyses at the wrists and ankles. There 
was no spasm or paralysis. The knee-jerks were equal and 
normal. The rectal temperature was 100.2° F.; the pulse, 
120; the respiration, 25. She weighed, without her clothes, 
thirty and one-half pounds (the average is forty- three pounds). 
The urine was of normal color, clear, acid in reaction and 
contained no albumin or sugar. The sediment contained a 
few squamous cells and leucocytes. 



Blood. 




Hemoglobin, 


42% (Sahli) 


Red corpuscles, 


3,600,000 


White corpuscles. 


32,000 


Mononuclears, 


44% 


Polynuclear neutrophils, 


52% 


Eosinophiles, 


2% 


Mast cells, 


2% 



There was moderate variation in the size and shape of the 
red corpuscles with a tendency to macrocytosis. There was 
moderate achromia and marked polychromatophilia. Four 
normoblasts and three megaloblasts were seen in counting 
one hundred white cells. 

A stool, which was examined the day after taking 22 
grams of fat, 223 grams of carbohydrates and 26 grams 
of proteid, was brown, foul and contained considerable 
mucus. There was no gross pus, but a few leucocytes 
were seen. No red corpuscles were seen with the micro- 
scope. There was a moderate excess of neutral fat and a 
considerable excess of fatty acids and soaps. There was no 
starch. 

A skin tuberculin test was negative. 

The Roentgenographs of the wrists, ankles and knees 
showed the typical changes of rickets. 



234 CASE HISTORIES IN PEDIATRICS. 

Diagnosis. She has, without question, a chronic dis- 
turbance of digestion with acute exacerbations and with in- 
tolerance of fat. The large, pendulous abdomen is, in all 
probability, due to the enlargement of the intestines as the 
result of the chronic indigestion. The dullness in the flanks 
and the slight change in dullness with change of position is, 
without question, due to the presence of liquid feces in the 
lax intestines and not to free fluid in the peritoneal cavity. 

The rosary, the flaring of the lower chest, the scoliosis, the 
knock-knees and the enlargement of the epiphyses are posi- 
tive signs of rickets. If the testimony of the parents as to 
her good health during the first two years and that of her 
physician that she showed no signs of rickets before she was 
five years old can be believed, the rickets must have devel- 
oped recently, that is, it is a case of Late Rickets. The 
Roentgenographs show signs of active, not of healed, rickets 
and, therefore, corroborate the diagnosis. 

The macrocytosis, the presence of megaloblasts and the 
slight excess of mononuclear cells suggest to a certain extent 
pernicious anemia. The other characteristics of the blood 
are, however, those of Secondary Anemia. The blood 
picture, as a w^hole, is typical of the secondary anemia with 
leucocytosis seen in infancy. It is probable that in connec- 
tion with the rickets, usually a disease of infancy, there has 
also been a reversion of the hemopoietic system with the 
resulting formation of a younger type of blood. Enlargement 
of the liver and spleen are not uncommon in the disturbances 
of nutrition associated with rickets and anemia in infancy. 
It is presumable that the enlargement in this instance is also 
simply a manifestation of the same disturbance of nutrition 
which is the cause of the rickets and the anemia. 

The sequence of events has been apparently as follows: 
chronic indigestion with acute exacerbations and with in- 
tolerance of fat; disturbance of the nutrition as the result of 
the chronic indigestion, with the development of rickets, 
secondary anemia and enlargement of the liver and spleen. 
It is possible that the intolerance of fat has resulted in suf- 
ficient loss of calcium to result in the development of rickets. 
This is, however, somewhat doubtful. The whole picture is 



DISEASES OF NUTRITION. 235 

a very common one in infancy, but extremely rare in child- 
hood. 

Prognosis. She will almost certainly recover in time. It 
will require, however, many months, and probably years, of 
the greatest attention to her diet, hygienic surroundings and 
care. 

Treatment. The treatment consists primarily in regula- 
tion of the diet to her digestive capacity. Fat must be 
entirely cut out and the required number of calories made up 
by an extra amount of carbohydrates and proteid. The 
elimination of the fat from the food will presumably influence 
the rachitic process favorably. There is no indication for 
the administration of calcium salts, because there is certainly 
no deficiency in these salts in the food, the disturbance of 
ossification being due to inability either to absorb or to make 
use of them. The author has not seen any better results 
when cod liver oil and phosphorus have been given in rickets 
than when they have not, and seldom prescribes them. 
Intolerance of fat would seem, moreover, to contraindicate 
the use of cod liver oil in this instance. It will be well to 
give her both arsenic and iron for the anemia. She should 
be given one minim of Fowler's Solution, well diluted, three 
times daily, after meals. The dose should be increased one 
minim daily until toxic symptoms appear. It should then 
be reduced to the last dose which did not cause toxic symp- 
toms and kept there. She should be given ten grains of the 
saccharated oxide of iron or ferratin, three times daily, after 
meals. She should be given, of course, the maximum pos- 
sible amount of fresh air and sunshine, should be kept in bed 
for the present and guarded in every way against fatigue and 
exposure. 



236 CASE HISTORIES IN PEDIAtRICS. 

CASE 63. Pauline P. was bom July 15 at full term after 
an instrumental labor, was normal at birth and weighed 
eight pounds. Her father learned, about July i, that he had 
pulmonary tuberculosis and went West about two weeks 
after she was born. She was put at once on modified milk 
and did very well. About October i, when ten weeks old, she 
went West and joined her father. He slept out of doors and 
was very careful not to expose her to infection. After going 
West she was fed on equal parts of whole milk and water, 
prepared with Mellin's Food. This did not agree with her 
very well. She returned to her home in the East, February i, 
having been with her father about four months. She was 
then put on a mixture of whole milk and water, prepared with 
" Peptogenic Milk Powder." In the course of the preparation 
of the food, the milk was brought to a boil. She had been 
taking this food for three and one-half months when she was 
seen. She had taken and digested it well and gained steadily 
in weight. 

She stopped creeping about April 20. April 26 she fell out 
of a low chair to the floor, striking on her forehead. She did 
not seem hurt, except for a bruise on the right side of th^ 
forehead. Beginning with the next day she cried a great 
deal during her bath, and May i it was noticed that motions 
of the legs caused pain. The pain on motion of the legs 
increased. She lay on her back and kept her legs drawn up. 
When quiet in this position she had no pain. She was very 
much afraid of being touched and began to cry when any one 
approached her. The upper gums became inflamed about 
May 10. Her appetite had fallen off and she had lost some 
weight and much color since the appearance of the pain, 
although she had shown no signs of indigestion. Her tempera- 
ture had not been taken, but she had not appeared feverish. 
The urine had not stained the diapers. She was seen in con- 
sultation May 17, when ten months old. 

Physical Examination. She was fairly developed and nour- 
ished and moderately pale. She was very much afraid of 
being touched. The fontanelle was level. There was an 
ecchymosis, about the size of a five-cent piece, on the right 
side of the forehead. The two lower central incisors had 



DISEASES OF NUTRITION. 237 

erupted and the gum was normal about them. The upper 
gum was distended by the four incisors. The gum was a 
little purplish over them. The tongue was clean and the 
throat normal. There was a slight rosary. The heart, lungs 
and abdomen were normal. The liver was palpable 2 cm. 
below the costal border in the nipple line ; the spleen was not 
palpable. The spine was perfectly flexible. She preferred to 
lie on her back with the legs flexed at the hips and knees. 
Neither active nor passive motions were limited, but motions 
at the hips and knees caused much pain. There was no 
definite tenderness and no swelling about the bones or joints. 
The arms were not tender and were used freely without dis- 
comfort. The knee-jerks were equal and normal; Kernig's 
sign was absent; sensation to touch and pain was normal. 
There was no enlargement of the peripheral lymph nodes. 
The rectal temperature was 98.6° F, 

Diagnosis. Tuberculosis of the spine or hip-joints had been 
seriously considered by the physician in charge because of 
the known exposure to tuberculosis. The normal mobility 
of the spine and at the hips, together with the normal tempera- 
ture, rule this out. The grandmother thought that the fall 
might be the cause of the pain. The baby had, however, 
stopped creeping before the fall and showed no evidence of 
injury at the time. It is hard to conceive, moreover, of an 
injury which would involve both legs and not show any 
physical signs. Infantile paralysis and multiple neuritis 
might be thought of on account of the pain. Infantile paraly- 
sis can be at once excluded because of the absence of paralysis 
and the presence of normal reflexes after three weeks. Multi- 
ple neuritis can be ruled out because at this age it is almost 
always a sequela of diphtheria and, consequently, is seldom 
accompanied by pain. The reflexes are intact, moreover, and 
there is no paralysis or disturbance of sensation. Osteomye- 
litis and periosteitis seldom occur in more than one place at a 
time and can be excluded on the good general condition and 
the absence of fever and localized tenderness. The combina- 
tion of pain without physical signs is characteristic of rheuma- 
tism in early life. Rheumatism almost never occurs in 
early infancy, however, and will not account for the swollen 



238 CASE HISTORIES IN PEDIATRICS. 

and purplish gum. The slow onset, the unwillingness to use 
the legs, the pain on motion and the position in which the 
legs are held are almost pathognomonic of Scurvy and justify 
that diagnosis without any other evidence. The combination 
of these signs with the swollen, purplish gum, another char- 
acteristic sign of scurvy, cannot be accounted for in any other 
way, and makes the diagnosis absolute. The ecchymosis 
on the forehead may be a scorbutic manifestation but, on 
the other hand, may be simply the result of the fall. The 
prolonged use of boiled milk is corroborative evidence of 
the diagnosis of scurvy, as it is undoubtedly one of the causes 
of this disease. 

Prognosis. The prognosis is absolutely good. She will be 
perfectly well in a week if properly treated. 

Treatment. The first step in the treatment is to remove 
the probable cause of the disease, that is, boiling the milk. 
There seems to be no reason for changing the composition of 
the food as she was doing very well on it except for the scurvy. 
The mixture contains 2% of fat, 6.50% of sugar and 1.75% of 
proteids. It is always unwise to continue peptonization over 
long periods because it tends to weaken the digestive power. 
It will, therefore, be wise to replace the " Peptogenic Milk 
Powder ** (which is composed largely of milk sugar) by milk 
sugar and to add starch, in the form of barley water, to hinder 
the formation of large curds. The following combination is a 
suitable one: 

Whole milk, 24 ounces 

Barley water (1.50% starch), 24 ounces 
Milk sugar, 4 rounded tablespoonfuls 

This mixture contains 2% of fat, 6.50% of sugar, 1.75% of 
proteids and 0.75% of starch. The sugar should be mixed 
with the hot barley water and the mixture cooled before the 
milk is added. She should take six feedings, of from seven 
to eight ounces. 

She will undoubtedly recover in time on the " fresh " food, 
but recovery will be slow. Fruit juices, however, have a 
specific action in infantile scurvy, and should, therefore, 
always be given. They will cure the process even if the cause 
is not removed. Orange juice is the best, because it is the 




Deformity of legs in Scurvy. 



DISEASES OF NUTRITION. 239 

most readily taken. Babies seldom object to it. It may be 
given plain or diluted with water. There is no objection to 
the addition of cane sugar if the orange is sour. It may be 
given all at one dose or divided into two doses. It is best 
given about an hour before a feeding, when the stomach is 
empty. One ounce is the proper dose. Less than this may 
be ineffectual, more is unnecessary. She should have, there- 
fore, an ounce of orange juice daily. This dose should be 
continued until all symptoms of the disease have disappeared. 
It will be wise to keep it up for some time longer, but the dose 
need not be as large. 



240 CASE HISTORIES IN PEDIATRICS. 

CASE 64. Lallah P. was the first child of healthy parents. 
She was born at full term and weighed six and one-half 
pounds. She had always been fed on pasteurized milk 
prepared at a laboratory. She had done very well until she 
was six months old, when she ceased to gain and lost her 
appetite. When she was seven months old her mother noticed 
that the urine at times stained the diapers red. This staining 
was attributed by the physician in charge to uric acid. It 
continued intermittently for a month, when the urine was 
examined and found to contain fresh blood, but no casts. 
Micturition was not increased in frequency and was not 
painful. There were no other symptoms whatever except 
failure to gain in weight. She was seen in consultation when 
eight months old. 

Physical Examination. She was well developed and nour- 
ished, but somewhat pale and flabby. She was bright and 
happy. The anterior fontanelle was 3 cm. in diameter and 
level. The mouth and throat were normal. There were no 
teeth. There was no rosary. The heart and lungs were nor- 
mal. The level of the abdomen was somewhat above that 
of the thorax; it was everywhere tympanitic and nothing 
abnormal could be detected. Very careful examination failed 
to find any enlargement of the kidneys. The liver was pal- 
pable 2 cm. below the costal border in the nipple line; the 
spleen was not palpable. The extremities were normal. 
There was no spasm, paralysis or tenderness. Neither active 
nor passive motions caused pain. The knee-jerks were equal 
and normal; Kernig's sign was absent. There was a slight 
general enlargement of the peripheral lymph nodes. She 
weighed thirteen pounds. 

The urine was pale with a slightly reddish tinge, feebly 
acid, of a specific gravity of 1,006 and contained a trace of 
albumin. The sediment showed a few red blood corpuscles 
and an occasional leucocyte, but no other formed elements. 

Diagnosis. The only causes of hematuria, not associated 
with bleeding elsewhere, in infancy, which really deserve 
consideration are irritation from crystals of uric acid, sarcoma 
of the kidney and scurvy. Tuberculosis of the kidney is 
almost unheard of at this age, and, when present, the urine 



DISEASES OF NUTRITION. 24I 

more often contains pus than blood. Vesical calculi are also 
very unusual at this age and rarely cause hematuria at any 
age unless the patient is very active. Irritation from uric 
acid crystals can be ruled out in this instance on the examina- 
tion of the urine. The absence of frequent and painful 
micturition also make it improbable. The hematuria is 
perfectly consistent with either sarcoma of the kidney or 
scurvy. Pain is rare in sarcoma at this age, and constitutional 
symptoms are usually absent until the tumor has attained 
considerable size. Hematuria appears before the tumor is 
palpable in about forty per cent of the cases. Hematuria 
is not infrequently the earliest symptom of scurvy, appearing 
before pain and tenderness in the extremities or sponginess of 
the gums. An absolute diagnosis between sarcoma and scurvy 
in this instance is, therefore, impossible. The chances are 
very much in favor of scurvy, however, because of the much 
greater frequency of scurvy than of sarcoma of the kidney, 
the long continuance of the pasteurization of the milk, which 
predisposes to the development of scurvy, and the loss of 
appetite and failure to gain in weight, which usually precede 
and are almost invariably associated with scurvy. The 
chances are, in fact, so much in favor of Scurvy that it is 
justifiable to make a positive diagnosis of this disease and to 
consider sarcoma as merely an extremely remote possibility. 

Prognosis. The prognosis is perfectly good. The bleeding 
will almost certainly cease within a week under proper 
treatment. 

Treatment. The treatment is simple. It consists in stop- 
ping the pasteurization of the milk and in giving an ounce of 
orange juice daily. If it is inadvisable in any instance to omit 
pasteurization because of an unreliable supply of milk or hot 
weather, orange juice alone will cure the trouble. 



SECTION V. 

SPECIFIC INFECTIOUS DISEASES. 

CASE 65. Bessie F. was born November 21, 1894. She 
was seen in consultation May 10, 1900. Both her parents 
had died of pulmonary tuberculosis during the previous year. 
She had lived with them up to the time of their death. One 
brother, six years old, was well. There had been no other 
children. 

She had measles when two years old and was said to have 
had influenza in February, 1900. She began to complain of 
pain in the abdomen about the first of March, 1900. The 
pain continued for several weeks and then ceased. Swelling 
of the abdomen was noticed about the middle^of March and 
had slowly but steadily increased. Her appetite was good. 
She vomited after breakfast, however, two or three times a 
week. Her diet was a reasonable one for her age. Her bowels 
moved once in two or three days. The character of the move- 
ments had not been noted. She had had a cough during the 
day for about a month. She had lost both flesh and color. 

Physical Examination. She was well-developed and fairly 
nourished, but somewhat pale. She was bright and happy. 
Her tongue was moist and moderately coated. The heart 
was normal. There was slight dullness in both backs below 
the eighth space, with normal but somewhat diminished 
respiration and voice sounds. Fine, crackling, moist rales 
were occasionally heard in the dull area. The upper border of 
the liver flatness in the nipple line was in the fourth space. 
The lower border of flatness was 3 cm. above the costal border. 
The splenic dullness could not be determined. The edge of 
the spleen was not felt. The abdomen was much enlarged 
and the walls were tense. The distention was uniform. There 
was no enlargement of the superficial abdominal veins. 
There was dullness in the lower portion and in both flanks. 

243 



244 CASE HISTORIES IN PEDIATRICS. 

While the child lay on her back the upper line of dullness was 
concave. The rest of the abdomen was tympanitic. The 
area of dullness changed with change of position. A fluid 
wave was present. There was no edema of the extremities or 
of the face. There was no enlargement of the superficial 
lymph nodes. The rectal temperature was 99° F. ; the pulse, 
120. The urine showed nothing abnormal; the blood was 
not examined. 

Diagnosis. The principal abnormality observed in the 
physical examination is the presence of fluid in the abdominal 
cavity. Both borders of the liver are higher than they should 
be, while the total width of the liver flatness is normal, show- 
ing that the liver is merely displaced upward by the pressure 
of the fluid in the abdomen. The absence of the splenic 
dullness is presumably due to its displacement upward and 
backward. The rales show that the dullness and diminished 
respiration and voice sounds in the lower backs are not due 
to fluid in the pleural cavities. They are satisfactorily ex- 
plained by the displacement of the liver upward and the 
consequent compression and congestion of the lower portions 
of the lungs. This condition also explains the cough. 

The dullness in the flanks, the concavity of the upper border 
of the dullness, when she lies on her back, and the change of 
the area of dullness with change of position prove that the 
fluid is free in the abdomen and not confined in an ovarian 
or other cyst. 

Free fluid in the abdominal cavity may be due to causes 
either within or without the cavity. When due to causes 
outside of the abdominal cavity, there is usually edema of 
other parts of the body and, if the trouble is in the heart, the 
signs of passive congestion in other organs. The absence of 
edema and of the signs of passive congestion and the normal 
condition of the heart and urine rule out all causes outside of 
the abdomen in this instance. 

The possible causes located within the abdomen are those 
diseases and conditions which result in portal congestion and 
diseases of the peritoneum. The two causes of portal con- 
gestion are disease of the liver and compression of the portal 
vein. The absence of enlargement of the spleen and of the 



SPECIFIC INFECTIOUS DISEASES. 245 

superficial abdominal veins makes portal congestion very 
improbable. The normal size of the liver practically excludes 
disease of this organ. The age of the child is also much against 
any chronic disease of the liver. The absence of an alcoholic 
or syphilitic history and of all signs of syphilis, the two most 
common causes of chronic disease of the liver at this age, 
makes disease of the liver still more improbable. Compression 
of the portal vein is usually due to a new growth of some sort, 
usually enlarged lymph nodes, they, in turn, usually being 
tubercular. In the light of the prolonged exposure to tuber- 
culosis, a tubercular infection of the abdominal lymph nodes 
is not at all unreasonable in this instance and cannot be 
excluded on the negative physical examination, because an 
enlarged lymph node, too small to be palpable, can, if located 
in the right place, exert much pressure on the portal vein. 
As already explained, however, the absence of enlargement of 
the spleen and of the superficial abdominal veins makes 
portal congestion very improbable. 

The diseases of the peritoneum to be considered are chronic 
serous peritonitis, malignant disease of the peritoneum and 
tubercular peritonitis. There is much doubt as to whether 
there is such a disease as chronic serous peritonitis. If there 
is, it almost never occurs before puberty. Malignant disease 
of the peritoneum is extremely rare, almost always results in 
palpable tumors and is accompanied by greater cachexia than 
is present in this instance. Both of these conditions can be 
excluded, therefore, if any other more reasonable explanation 
can be found. Tubercular peritonitis of the ascitic form is 
not at all uncommon at this age; the onset and progress of 
the illness in this instance are most characteristic of this 
disease; the prolonged exposure to tuberculosis makes a 
tubercular infection very probable. The diagnosis of Tuber- 
cular Peritonitis seems, therefore, amply justified. 

An examination of the ascitic fluid will aid' materially In 
confirming the diagnosis. The fluid from portal congestion 
is a transudation; that from disease of the peritoneum, an 
exudation. In the former the specific gravity of the fluid is 
below 1,015 ^-nd it usually contains less than 2% of albumin, 
while in the latter, the specific gravity is above 1,015 ^^^ it 



246 



CASE HISTORIES IN PEDIATRICS. 



usually contains more than 4% of albumin. The cells in a 
transudation are usually few and endothelial in character. 
The fluid in tubercular peritonitis usually contains many 
cells, and these are largely lymphocytes. Characteristic 
tumor cells are not infrequently found in the fluid when there 
is malignant disease of the peritoneum. Tubercle bacilli 
may often be found in the fluid in tubercular peritonitis, and 
animal inoculations are almost always positive. The diagno- 
sis of tubercular peritonitis is, however, justified in this 
instance without an examination of the fluid. 

A skin tuberculin test would be of interest in this child, but 
not of great aid in diagnosis. If positive, it merely shows that 
the child has a tubercular focus somewhere, not that the 
trouble in the abdomen is tubercular, although it is, of course, 
important corroborative evidence. If negative, it does not 
prove that the trouble in the abdomen is not tubercular, 
because the test is often negative when the tuberculosis is 
of J the miliary type, as it is in this instance. 

Prognosis. Favorable points in this instance are the 
unusually good general condition, the absence of fever and 
of evidences of tuberculosis elsewhere. Her chances of re- 
covery are probably about even, provided she can have proper 
treatment. 

Treatment. The author does not believe in a routine 
operative treatment in this disease, even in the ascitic form, 
and does not think that, on the whole, the cases that are 
operated on do any better than those that are not. He 
believes in leaving the fluid alone unless it is causing too 
much discomfort or doing harm by the compression of other 
organs. He then believes in tapping rather than in opening 
the abdomen, leaving the latter as the last resort when the 
abdomen fills up rapidly after tapping. The treatment as 
regards the ascites is, therefore, in this instance, expectant. 
The further treatment is that of tuberculosis in general: 
an out-of-door life, day and night; quiet and forced feeding. 
There is no indication for drugs. 



SPECIFIC INFECTIOUS DISEASES. 247 

CASE 66. Mary D., seven years old, was the child of 
healthy parents. Three other children were well and one had 
died at birth. There was no tuberculosis in the family and no 
known exposure to tuberculosis. 

She was born at full term after a normal labor. She was 
nursed for eight months and did very well. During her fourth 
year she had had diphtheria, measles, whooping-cough and 
chicken pox, and was not in very good health during the next 
year. Since then she had been very well indeed. 

She was taken suddenly sick July 30 with a pain in the 
abdomen, but did not go to bed. The next day she vomited 
everything she took except water, and the pain continued. 
The pain and vomiting were worse on August i and she 
stayed in bed most of that day. She vomited the morning of 
August 2, but had no pain. She had no pain and did not vomit 
on the 3d and 4th, but stayed in bed. The bowels had moved 
regularly; the character of the movements was not known. 
She entered the Children's Hospital August 5. 

Physical Examination. She was well developed and nour- 
ished. She lay comfortably in bed and did not look acutely 
sick. The pupils were equal and reacted to light and accom- 
modation. There was no rigidity of the neck. There was 
moderate pallor of the skin and mucous membranes. The 
tongue was moist and covered with a thin white coat. The 
throat was normal. The heart and lungs showed nothing 
abnormal. The liver flatness extended from the upper border 
of the sixth rib to the costal margin; the edge was not felt. 
The upper border of splenic dullness was in the eighth space; 
the edge was not felt. The abdomen was full and the walls 
were held rigidly. Examination was difficult, deep palpation 
being impossible. There were no rose spots. An indefinite 
mass was felt above the symphysis pubis, extending one half 
way to the umbilicus. This mass was still present after the 
bladder had been emptied by catheterization. There was 
also an indefinite resistance just above the right iliac crest. 
There was dullness in this region and over the mass in the 
hypogastrium. There was no shifting dullness and no fluid 
wave. There was slight general tenderness throughout the 
abdomen. The extremities showed nothing abnormal. There 



248 CASE HISTORIES IN PEDIATRICS. 

was no spasm or paralysis. The knee-jerks were not obtained. 
The plantar reflexes were normal. There was no edema. 
There was slight enlargement of the cervical lymph nodes. 
Rectal examination showed nothing abnormal. The tem- 
perature was 102'^F.; the pulse, 94; the respiration, 25. 

Urine (drawn by catheter): Normal color, acid, 1,018, no 
albumin or sugar. The sediment contained a few leucocytes 
and a few fine granular and hyaline casts. 

Blood: Leucocytes, 13,700. 

Diagnosis. The points which are of value in the diflFerential 
diagnosis in this instance are an acute abdominal affection 
of five days' duration ; the good general condition ; a definite 
tumor in the hypogastrium when the bladder is empty; an 
indefinite resistance and dullness above the right iliac crest; 
the negative rectal examination; and the slight degree of 
the leucocytosis. 

The only diseases which are really worthy of consideration 
are appendicitis, some disease of the female pelvic organs 
and tubercular peritonitis. The urine shows merely a mild 
degenerative nephritis, which is of no importance either in 
diagnosis or In prognosis. The fever is consistent with all of 
these diseases and is, therefore, of no aid in the differential 
diagnosis. 

The history is much more suggestive of appendicitis than 
of the other conditions. Against it are the good general 
condition in spite of the tumor in the abdomen, the location 
of the tumor, the presence of another indefinite mass, the 
negative rectal examination and the slight degree of the 
leucocytosis. 

The location of the tumor is consistent with some inflam- 
matory process in the female pelvic organs. Against this 
diagnosis are the extreme rarity of inflammatory processes 
in these organs at this age, the location of the other indefinite 
mass, the negative rectal examination (which at this age 
amounts to a vaginal examination), and the slight degree of 
the leucocytosis. 

In favor of tubercular peritonitis is the presence of two 
masses, presumably due to the same cause, which do not 
correspond to the findings in any other condition and which 



SPECIFIC INFECTIOUS DISEASES. 249 

are consistent with the lesions found in tubercular peritonitis. 
The fact that these masses cannot be felt on rectal examina- 
tion is not inconsistent with the location of the tumors in 
tubercular peritonitis, but is with that of the tumors of ap- 
pendicitis and inflammatory processes in the pelvic organs. 
The slight degree of the leucocytosis is also consistent with 
tubercular peritonitis. The absence of a family history of or 
exposure to tuberculosis and the acuteness of the onset may 
be urged against the diagnosis of tubercular peritonitis. A 
tubercular family history is, however, of little or no Impor- 
tance either for or against tuberculosis unless there has been 
exposure. The absence of a history of exposure to tuberculo- 
sis does not count In any way against tuberculosis, although, 
of course, a history of exposure points strongly toward it. 
The history of measles and whooping-cough in the past, 
both of which are known to predispose to the development of 
tuberculosis. Is of some importance in this instance. An 
onset as acute as in this Instance is unusual, but not un- 
common enough to count much against the diagnosis of 
tubercular peritonitis. The good general condition Is more 
consistent with this disease than with the others under con- 
sideration. The diagnosis of Tubercular Peritonitis Is, 
therefore, justified. It is undoubtedly of the caseous or 
fibrocaseous type. 

Prognosis. The prognosis in this type of tubercular 
peritonitis is not nearly as good as In the ascitic form. She 
probably has about one chance in three of recovery. 

Treatment. Operation cannot possibly do any good in this 
instance. The masses are too extensive to be removed, and 
opening the abdomen cannot of itself be of any benefit. The 
further treatment is that of tuberculosis in general; an out- 
of-door life day and night, quiet and forced feeding. There 
is no indication for drugs. 



250 CASE HISTORIES IN PEDIATRICS. 

CASE 67. Olga R., seven years old, was the fourth child 
of healthy parents. The other children were well and there 
had been no miscarriages. There was no history of tuber- 
culosis in either family and there had been no known exposure 
to it. She was nursed for ten months and was very well 
until she had the diphtheria, when four years old. She had 
not been as vigorous since then, but had had no illnesses, 
except a primary pleurisy with effusion a year before. 

She began to cough a little, early in July. She did not 
seem sick, however, until two weeks later, when she became 
somewhat feverish and lost her appetite. The fever gradu- 
ally increased and after four days she went to bed and re- 
mained there. The fever had continued, but the cough 
had diminished. She had perspired freely at night, but 
had had no chills. Her appetite had been very poor. 
She had vomited twice the night before. The bowels had 
moved daily without help and the stools had appeared 
normal. She had complained of pain in the abdomen for 
several days. She was admitted to the Children's Hospital, 
August 5. 

Physical Examination. She was well developed but poorly 
nourished. Her skin was somewhat pale, but the mucous 
membranes were of good color. She was perfectly clear 
mentally. The pupils were equal and reacted to light. 
Her tongue was moist and covered with a thick, white coat. 
The heart was normal. There was slight dullness with 
slightly diminished but vesicular respiration on the left side 
below the fifth rib in the mid-axillary line and the eighth in 
the scapular line. There was no change in the vocal resonance 
or tactile fremitus and no friction rub nor riles were heard. 
The liver was not palpable. The upper border of the splenic 
dullness was at the ninth rib, the edge was not palpable. 
The level of the abdomen was slightly below that of the 
thorax. It was everywhere tense and generally tender. 
The muscular spasm and tenderness were, however, most 
marked in the right lower quadrant. The abdomen was 
tympanitic throughout and no masses could be felt. There 
were no rose spots. There was no spasm or paralysis, but she 
lay with her legs drawn up. The knee-jerks were equal and 



SPECIFIC INFECTIOUS DISEASES. 25 1 

normal. Kernig's sign was absent. There was no enlarge- 
ment of the peripheral lymph nodes. The rectal examina- 
tion showed nothing abnormal. The rectal temperature was 
103.8° F.; the pulse, 148; the respiration, 40. 

The urine was normal in color, turbid, acid in reaction, 
of a specific gravity of 1026, and contained no albumin or 
sugar. The sediment consisted of amorphous urates and a 
few small, round cells. 

The leucocytes numbered 11,700. 

The Widal test was negative. 

Diagnosis. The absence of rose spots and enlargement of 
the spleen, together with the negative Widal reaction after 
two weeks, the frequent pulse and the sunken, rigid abdo- 
men rule out typhoid fever. Appendicitis is strongly sug- 
gested by the greater intensity of the muscular spasm and 
tenderness in the right lower quadrant. The duration of the 
illness before the onset of pain in the abdomen and vomiting, 
the regular action of the bowels, the absence of dullness and 
tumor in the right iliac fossa and the negative rectal exami- 
nation are very much against it. The most important point 
against it, however, is the normal white count, an increase 
in the number of white cells being a constant accompaniment 
of appendicitis, unless the system is overwhelmed by the 
toxemia. The good general condition shows that this is 
not the case in this instance. Appendicitis can, therefore, 
be excluded. The low white count in combination with the 
good general condition also rules out all forms of septic 
general peritonitis. 

There is, nevertheless, evidently some extensive inflam- 
matory process going on in the abdomen, almost certainly 
in the peritoneum. The only acute general disease of the 
peritoneum which is not accompanied by leucocytosis, pro- 
vided that the patient is not overwhelmed by toxemia, as 
this child is not, is tuberculosis. The diagnosis of Tuber- 
cular Peritonitis is, therefore, a reasonable one, and seems 
warranted by the facts. The history of the primary serous 
pleurisy, which, in childhood as in later life, is almost inva- 
riably tubercular, is another point in favor of this diagnosis. 
The dullness and diminished respiration in the lower left 



252 CASE HISTORIES IN PEDIATRICS. 

back and axilla are probably due to thickening of the pleura 
as the result of this illness. 

Prognosis. She is not in any immediate danger. The 
acuteness of the symptoms will probably last but a short 
time, after which the course and prognosis will be that of 
tubercular peritonitis in general. The fact that there has 
also been a tubercular infection of the pleura in this instance 
renders her chances of recovery rather less favorable than the 
average. 

Treatment. There is at present no indication for a laparo- 
tomy. She must be kept quiet in bed, given a maximum 
amount of fresh air and sunlight and fed carefully. Her diet 
for the present should consist of milk, broth, cereals, milk 
toast, baked custard and junket. The temperature is not 
high enough to require special treatment. There is at 
present no indication for the use of stimulants. 



SPECIFIC INFECTIOUS DISEASES. 253 

CASE 68. Frank S. was the only child of healthy parents. 
He had always been breast-fed and had never had any dis- 
turbance of the digestion. He lived during the first two 
months of his life in a house with a young man who had 
pulmonary tuberculosis and had since died of it. The young 
man had, however, not been much with him. He was well 
until he was a little over five months old, when he had what 
was called bronchopneumonia. He did not recover well from 
this illness and the cough continued. He had lost weight 
and strength rapidly during the last month. He was ad- 
mitted to the Infants' Hospital when eight months old. 

Physical Examination. He was fairly developed and 
nourished and somewhat pale. The anterior fontanelle was 
two cm. in diameter and slightly depressed. The bones of the 
skull overlapped a little. The mouth and throat were nor- 
mal. He had no teeth. There was a moderate rosary. The 
heart was normal. There was dullness in the left front above 
the fourth rib and in the back above the spine of the scapula. 
The sense of resistance was not markedly increased. The 
respiration was nowhere normal in this area, being in some 
places bronchial and in others bronchovesicular. The voice 
sounds were increased. There was no change in the tactile 
fremitus. There were numerous fine, medium and coarse, 
high-pitched, moist rales in this area. There was an occa- 
sional fine, moist rale in both lower backs. The right lung 
was otherwise normal. The abdomen was sunken, but 
showed nothing else abnormal. The lower border of the 
liver was just palpable below the costal border in the nipple 
line. The spleen was not palpable. The extremities and 
genitals were normal, as were the deep reflexes. There was 
a general slight enlargement of the peripheral lymph nodes. 
The rectal temperature was 98.6° F.; the pulse, 120; the 
respiration, 30. He weighed eleven and one-half pounds. 

Diagnosis. The only abnormal physical signs outside of 
those in the lungs are the rosary and the general evidences of 
malnutrition. The rosary being the only sign of rickets, it is 
fair to conclude that the rickets is an unimportant factor. It 
is also reasonable to assume that, since he has always been 
nursed and has never had any disturbance of digestion, the 



254 CASE HISTORIES IN PEDIATRICS. 

disturbance of the nutrition is due to the trouble in the lungs. 
The fine, moist rales at the bases of the lungs behind are 
undoubtedly due merely to defective expansion of the lungs. 
The signs at the left apex are those of partial solidification. 
This may be due to a chronic bronchopneumonia or to tuber- 
culosis. The long duration of the symptoms, the localiza- 
tion of the signs in one spot, the absence of evidences of 
bronchitis and the normal temperature are much against 
bronchopneumonia and in favor of tuberculosis. The history 
of a definite exposure to tuberculosis during the first two 
months of his life makes the diagnosis of Pulmonary Tuber- 
culosis almost certain. An absolutely positive diagnosis 
is impossible, however, on this data. It should be confirmed 
by an examination of the sputum or a skin tuberculin test. 
The failure to find tubercle bacilli in the sputum will not 
exclude tuberculosis, because it is often very difficult to get 
a satisfactory sample in infancy. A negative tuberculin test 
will practically rule it out, while a positive test at this age is 
almost certain proof that the suspected lesion is tubercular. 

Prognosis. The prognosis of pulmonary tuberculosis at 
this age is hopeless. He will probably live for three or four 
months, unless the process becomes disseminated, when he 
will die in a few weeks. 

Treatment. There is no medicinal treatment. Human 
milk, which he is now getting, is the best food for him. He 
must be given all the fresh air and sunlight possible. Further 
than this, nothing can be done. 



SPECIFIC INFECTIOUS DISEASES. 255 

CASE 69, Elizabeth N. was an only child. Her mother 
was well, but her father had *' bronchitis and pleurisy" and, 
being unable to w^ork, remained at home to take care of her 
while her mother went out to work. She was nursed for 
three months, after which she was fed on condensed milk. 
She had never had any disturbance of the digestion, but dur- 
ing the last few weeks her appetite had been very poor. 
She began to cough when five months old. She was treated 
in the wards of the Children's Hospital for ten days, when 
six months old, for what was thought to be bronchopneu- 
monia. When she was discharged the lungs were normal 
except for slight dullness in the lower left back. Her tem- 
perature had been normal for five days. She was readmitted 
to the Children's Hospital when she was eight months old. 
The cough had persisted, being worse during the last two 
weeks. She had recently lost weight very rapidly. 

Physical Examination. She was poorly developed and 
nourished, pale and feeble. The anterior fontanelle was one 
and one-half cm. in diameter and sunken. The bones of 
the skull overlapped. The throat was slightly reddened and 
the tongue slightly coated. She had two teeth. There was 
a slight rosary. The right border of the cardiac dullness 
was two cm. to the right of the median line; the left and 
upper borders could not be determined because of the dull- 
ness in the left chest. The action was regular and the sounds 
normal. The left side of the chest moved less than the right. 
There was marked dullness over the whole left side, except 
between the spine of the scapula and its angle, where the 
percussion note was flat. The sense of resistance was some- 
what, but not markedly, increased. The respiration was 
everywhere diminished, in places being bronchial, in others 
bronchovesicular in character. There was a small area at 
about the middle of the scapula where it was amphoric. 
The voice sounds were loud and bronchial in the fiat area; 
diminished, but changed in character, elsewhere. The tactile 
fremitus was somewhat increased, especially in the flat area. 
A few medium and coarse moist rales were heard both in 
front and behind. There were also many fine and medium 
moist r^les in the right back. The abdomen was a little 



256 CASE HISTORIES IN PEDIATRICS. 

full, but otherwise normal. The liver was just palpable in 
the nipple line. The spleen was not palpable. The epiph- 
yses at the wrists and ankles were slightly enlarged and 
there was moderate clubbing of the fingers and toes. The 
peripheral lymph nodes were slightly enlarged. The rectal 
temperature was 99° F. ; the pulse, 140; the respiration, 55. 

The leucocyte count was 35,500. 

Diagnosis. There can be no doubt from the examination 
of the chest that there is more or less complete solidification 
of the whole left lung and, judging from the amphoric res- 
piration, a small cavity at about its middle. There is also a 
bronchitis on the right side. There are no evidences of an 
accumulation of fluid. It is safe to conclude from the long 
duration of the symptoms, the emaciation without disturb- 
ance of the digestion and the clubbing of the fingers and toes 
that the condition is a chronic one. The only disease which 
at this age can cause such extensive solidification with cavity 
formation, limited to one lung, is tuberculosis. Further evi- 
dence in favor of tuberculosis is the father's illness, which is 
almost certainly tuberculosis. There is, therefore, every 
reason why she should have tuberculosis. The large number 
of white cells does not count against it, because at this stage 
there is almost invariably a secondary infection with the 
pus organisms. The enlargement of the peripheral lymph 
nodes does not count either for or against tuberculosis, be- 
cause enlargement of the peripheral lymph nodes occurs in 
all disturbances of nutrition in infancy. The diagnosis of 
Pulmonary Tuberculosis is, therefore, the only one possible. 
The rosary and the enlargement of the epiphyses show that 
she also has a mild grade of rickets. 

Prognosis. The prognosis is absolutely hopeless. She 
probably will not live more than a week. 

Treatment. The treatment can be only symptomatic. 



SPECIFIC INFECTIOUS DISEASES. 257 

CASE 70. Elizabeth D. was 12 years old. Her father 
died of pulmonary tuberculosis before she was born. Her 
mother continued to live in the same house. Her only 
brother died of diabetes mellitus when he was ten years old. 
She had measles and mumps when four months old and had 
trouble with her digestion for a time when she was ten years 
old. She had always been tall and slight and rather easily 
tired. She had had a dry cough for three months, which 
was more troublesome during the day than at night. She 
had had no pain in her chest and had raised almost nothing. 
Her mother thought that she had been a little feverish in the 
late afternoon and early evening. Her appetite was good 
and she had no disturbance of the digestion. She had not 
been weighed for some months, but her mother thought that 
she had lost a little weight. 

Physical Examination. She was tall and slight, but of 
good color and did not look sick. She breathed quietly with 
her mouth shut. The throat was normal, the tongue nearly 
clean. The right chest moved somewhat less than the left 
and the respiratory sound was diminished over the whole of 
the right side. There was dullness with bronchovesicular res- 
piration (more nearly bronchial than vesicular), prolonged 
expiration, increased spoken and whispered voice, increased 
fremitus and an occasional high-pitched moist rale at the 
right apex in front above the third rib. The heart was 
normal. The liver and spleen were not palpable. The 
abdomen and extremities were normal. There was no en- 
largement of the peripheral lymph nodes. The mouth 
temperature was 99.4° F. She weighed, with her clothes, 
eighty- three pounds (average is 78.7 pounds). 

Diagnosis. The slow onset of the symptoms and the signs 
of partial solidification at the right apex, together with the 
slight fever and the history of exposure to tuberculosis in 
infancy, present such a characteristic picture of the develop- 
ment and early stage of Pulmonary Tuberculosis, as it 
occurs in later childhood, that there can be no doubt as to 
the diagnosis. The only other possibility is a local infection 
of the lung by the influenza bacillus. This is not at all 
probable but, in order to make the diagnosis positive, the 



258 CASE HISTORIES IN PEDIATRICS. 

Sputum should be examined and the skin tuberculin test 
tried. The finding of tubercle bacilli in the sputum will 
make the diagnosis absolute ; a positive tuberculin, reaction 
will be only corroborative evidence. 

Prognosis. The area of lung involved is comparatively 
small, she is in good general condition, her appetite and 
digestion are good, she has the reparative power of growth 
to help her. The chances are, therefore, if she has proper 
treatment, much in favor of recovery. 

Treatment. The treatment of pulmonary tuberculosis at 
this age is essentially the same as in adult life. She must 
leave school and devote all her energies to getting well. 
She should live out of doors day and night and for the pres- 
ent keep as nearly absolutely quiet as possible. She should 
have three regular meals daily and milk and eggs between 
them. There is no indication for drugs except possibly for 
some simple sedative, like chloroform water, to control the 
cough. 



SPECIFIC INFECTIOUS DISEASES. 259 

CASE 71. Margaret M. was admitted to the Infants* 
Hospital when 18 months old. She had lived with her mother 
up to the time of the latter's death from pulmonary tuber- 
culosis, a year before. She had been boarded out since then 
and the woman who brought her knew practically nothing as 
to her history. During the first two weeks of her stay in the 
hospital she took her food fairly well, did not vomit and had 
regular, somewhat constipated, but well digested movements. 
She lost three-quarters of a pound during this time. Her 
temperature varied irregularly between 100° F. and 103.5° F., 
her pulse between 120 and 140, and her respiration between 
45 and 50. The subcutaneous tuberculin test was not tried, 
because of the elevated and irregular temperature. The skin 
tuberculin test was unknown at that time. 

Physical Examination. She was poorly developed and 
nourished and moderately pale. The anterior fontanelle was 
three cm. in diameter and depressed. She had five teeth. 
The mouth and throat were healthy. She was able to sit up, 
but the spine showed a marked curve of weakness. There 
was a very slight rosary. The heart was normal, except for a 
soft, systolic murmur at the base. There was a venous hum 
in the neck. There was slight dullness with increased bron- 
chovesicular respiration, slightly increased voice sounds and 
an occasional high-pitched moist rale in the left front above 
the third rib. The lungs were otherwise normal. There was 
no dullness between the scapulae, but the bronchial voice was 
heard as low as the fourth dorsal spine. The lower border of 
the liver was palpable one cm. below the costal border in the 
nipple line. The spleen was not palpable. The level of the 
abdomen was that of the thorax. Nothing abnormal was 
detected in it. The extremities were normal. There was no 
spasm or paralysis. The knee-jerks were equal and normal. 
Kernig's sign was absent. There was a general slight en- 
largement of the peripheral lymph nodes. She weighed ten 
and one-half pounds. 

The urine was pale, acid in reaction, of a specific gravity 
of loio and contained neither albumin nor sugar. 



26o CASE HISTORIES IN PEDIATRICS. 



Blood. 




Hemoglobin, 


52% 


Red corpuscles, . 


4,528,000 


White corpuscles, 


13,800 


Small mononuclears, 


12% 


Large mononuclears. 


7% 


Polynuclear neutrophiles, 


80% 


Eosinophiles, 


1% 



There was considerable variation in the size of the red cells 
and slight irregularity in their shape and color No nucleated 
red cells were seen while counting 250 leucocytes. 

Diagnosis. The changes in the blood are characteristic of 
secondary anemia. The murmur at the base of the heart 
and the venous hum in the neck are undoubtedly due to the 
anemia. The absence of all evidences of indigestion during 
her stay in the hospital, although she lost weight rapidly 
during this time, shows that the malnutrition is not due to 
any disease of the gastro-intestinal tract. The fever and 
the signs in the lung are amply sufficient to rule out a simple 
disturbance of metaboHsm. The rosary, which is the only 
positive sign of rickets, is so slight that it is evident that the 
rickets is merely another evidence of the disturbance of nu- 
trition. The signs at the left apex and the fever suggest 
bronchopneumonia. The disturbance of nutrition is, how- 
ever, undoubtedly of long duration, there are no other foci in 
the lungs, no evidences of bronchitis and almost no leu- 
cocytosis. A tubercular infiltration will explain the physical 
signs at the left apex equally well, and, v/hen the prolonged 
exposure to tuberculosis during the first six months of her 
life is taken into consideration, seems much more probable. 
The disturbance of nutrition is, however, greater than would 
be expected from the limited extent of the process in the 
lungs and suggests the presence of tuberculosis elsewhere. 
The bronchial voice sound over the upper dorsal spines 
shows that there is enlargement of the tracheo-bronchial 
lymph nodes. Enlargement of these nodes is usually, but 
not always, due to tuberculosis. It is safe to conclude that 
they are tubercular in this instance. There is no positive 



SPECIFIC INPECTIOUS DISEASES 26 1 

evidence of tuberculosis elsewhere, the peripheral lymph 
nodes being enlarged so commonly in all disturbances of 
nutrition in infancy that it is impossible to tell whether they 
are or are not tubercular. The disturbance of nutrition is 
so marked, however, and the tendency to dissemination is so 
great in infancy, that it is safe to assume that there are other 
foci of tuberculosis in the body and that the process, instead 
of being simply a local one in the lungs, is a Chronic Dif- 
fuse Tuberculosis. 

Prognosis. The prognosis is absolutely hopeless. She 
probably will not live more than two or three weeks. 

Treatment. Nothing whatever can be done for her except 
to make her as comfortable as possible. 



262 <^SE HISTORIES IN PEDIATRICS. 

CASE "]2. George G., three years old, was the child of 
healthy parents. One other child was well and one had died 
of cerebrospinal mer^'ngitis " caused by a fall." There had 
been no miscarriages. There was no tuberculosis in the family 
and no known exposure to tuberculosis. He had always been 
perfectly well. 

It was noticed on September 4 that his appetite was poor 
and that he seemed dull, sleepy and tired. He continued in 
this condition, although up and about the house, until Sep- 
tember 10, when he went to bed. He vomited in the night 
and the next day seemed decidedly worse and began to com- 
plain of pain in the abdomen. That night he became restless, 
threw his head back on the pillow and " kicked out with his 
feet." He also became very cross and irritable. The irri- 
tability continued, but he remained conscious. He vomited 
again on September 12. The bowels were constipated from 
the beginning, moving only with enemata. The pain in the 
abdomen continued. He made no complaint of headache. 
Strabismus appeared on September 14 and persisted. That 
night he began to cry out as if in pain. This symptom con- 
tinued. He was admitted to the Children's Hospital 
September 16. 

Physical Examination. He was fairly well developed and 
nourished, but looked sick. He was dull mentally but con- 
scious. He could not speak plainly, but was able to make his 
wants known. He was irritable and cried out occasionally 
as if in pain. There was double convergent strabismus. 
He was able to see. The pupils were dilated and equal, but 
did not react to light. There was no discharge from the nose 
or ears. The lips were red and cracked. The tongue was 
dry and covered with a moderate brown coat. The tonsils 
were slightly reddened and prominent. There was no herpes. 
The heart and lungs showed nothing abnormal. The level of 
the abdomen was below that of the thorax; there was no 
definite muscular spasm; it was tympanitic and not tender; 
no masses were made out. The upper border of the liver 
flatness was at the upper border of the fifth rib ; the edge was 
palpable 3 cm. below the costal border in the nipple line. 
The spleen was not palpable. There were no rose spots or 



SPECIFIC INFECTIOUS DISEASES. 263 

petechiae. The head was not held backward, but there was 
slight rigidity of the neck and complete flexion was resisted 
and caused pain. There was no spasm or paralysis of the 
extremities. The knee-jerks were normal and equal. Ker- 
nig's and Babinski's signs were absent. There was no ankle 
clonus. Sensation to pain was normal. There was no en- 
largement of the peripheral lymph nodes. The rectal tem- 
perature was 102° F., the pulse no (normal is 100), the 
respiration 30. The urine was high-colored, strongly acid, 
of a specific gravity of 1,026, and contained neither albumin 
nor sugar. The blood showed 23,000 leucocytes. 

Diagnosis. The early history suggests nothing more than 
a disturbance of digestion. The completed history points 
strongly to meningitis, although typhoid with symptoms of 
meningeal irritation is a possibility. The strabismus, the 
dilated and reactionless pupils, the slight rigidity of the neck 
and the pain on motion, the absence of enlargement of the 
spleen and of rose spots and the leucocytosis are sufficient, 
when taken together, to positively rule out typhoid. The 
absence of retraction of the head and of marked rigidity of 
the neck, of spasm or paralysis of the extremities and of 
Kernig's and Babinski's signs, as well as of changes in the 
knee-jerks, is somewhat unusual, but not enough so to count 
materially against meningitis. The relatively low pulse is 
consistent with either condition. The diagnosis of menin- 
gitis is, therefore, certain. 

The diagnosis of meningitis, however, is not sufficient. It 
is necessary to go further and to determine the kind of menin- 
gitis. When meningitis does not develop in the course of 
some other acute disease it is practically invariably either 
tubercular or cerebrospinal, and other types do not need 
to be considered. The diagnosis in this instance, therefore, 
lies between the tubercular and cerebrospinal forms. The 
diagnosis between tubercular and cerebrospinal meningitis 
in infancy and early childhood is often a very difficult one, 
because most of the points which help in the diagnosis in later 
childhood are so uncertain at this age that little dependence 
can be placed upon them. In most cases, however, a very 
probable diagnosis can be made. 



264 CASE HISTORIES IN PEDIATRICS. 

In this instance the absence of a tubercular family history 
and of exposure to tuberculosis does not count at all against 
tubercular meningitis or in favor of cerebrospinal meningitis. 
The slow onset is in favor of the tubercular form, but does not, 
by any means, rule out the cerebrospinal. The absence of 
herpes and eruptions does not count against the cerebrospinal 
form or in favor of the tubercular, because herpes and 
eruptions are very unusual in cerebrospinal meningitis at 
this age. Retraction of the head, marked rigidity of the 
neck, spasm and paralysis of the extremities, Kernig's and 
Babinski's signs, and changes in the pupils may be absent 
in both, but are more often wanting in the tubercular 
form. The leucocytosis is in favor of cerebrospinal menin- 
gitis, but is not inconsistent with the tubercular form, in 
which a leucocytosis sometimes occurs. The weight of the 
evidence is, therefore, somewhat in favor of Tubercular 
Meningitis, enough so, in fact, to justify this diagnosis. 
There is, however, a reasonable possibility that the trouble 
really is cerebrospinal meningitis. The only way in which an 
absolute diagnosis can be made is by lumbar puncture. 
Since lumbar puncture is a harmless procedure, and since 
cerebrospinal meningitis can in many instances be cured by 
the'antimeningitis serum, a lumbar puncture should be done 
at once in order that he may have the advantage of the serum 
treatment if the disease is cerebrospinal meningitis. 

The normal cerebrospinal fluid is perfectly clear, like 
distilled water, does not form a fibrin clot on standing, and 
never contains more than 0.1% of albumin, or more than 
ten cells per cubic millimeter. The vast majority of these 
cells are mononuclear. The various forms of globulin tests 
are all negative. The fluid in tubercular meningitis is 
usually slightly turbid, sometimes clear, rarely very turbid 
or purulent, forms a fibrin clot on standing and contains more 
than 0.1% of albumin and more than twenty cells per cubic 
millimeter. The vast majority of these cells are mononuclear, 
usually lymphocytes, the percentage varying from 80 to 98. 
The proportion of polynuclear cells usually increases with the 
progress of the disease. Tubercle bacilli can be found in the 
fluid in about ninety per cent of the cases, if the examination 



SPECIFIC INFECTIOUS DISEASES. 265 

is careful enough. If the examination is hasty, they will 
usually be missed. A fluid should never be passed as normal 
because it appears clear when drawn. If a fibrin clot does not 
form in twenty-four hours, tubercular meningitis can be 
excluded. The fluid in cerebrospinal meningitis is usually 
markedly turbid, often purulent, sometimes nearly clear, 
forms a fibrin clot or a sediment of pus on standing, contains 
more than 0.1% of albumin and several hundred cells per 
cubic miUimeter. The vast majority of these cells are poly- 
nuclear, the percentage usually varying between 75 and 90. 
The percentage of mononuclear cells gradually increases and 
finally exceeds the polynuclear in cases which recover. The 
meningococcus is almost invariably present in the acute 
stage. One or more of the various globulin tests are positive 
in all forms of meningitis. Under normal conditions the 
cerebrospinal fluid flows out slowly, drop by drop, while in 
both forms of meningitis it usually, but not always, flows 
out more rapidly or even spurts out. 

The fluid obtained by lumbar puncture in this instance 
was slightly cloudy, showed a definite fibrin clot In six hours, 
and contained one hundred and twenty-five cells to the 
cubic millimeter, 83% of which were lymphocytes. No 
organisms were seen in the examination of one cover slip. 
The diagnosis of tubercular meningitis Is, therefore, verified 
by the results of the lumbar puncture. 

Prognosis. It is true that there are a few instances on 
record of recovery from tubercular meningitis. These are, 
however, so few in comparison with the vast number of fatal 
cases that It Is not justifiable to give anything but an abso- 
lutely hopeless prognosis. 

Treatment. There Is no curative treatment for tubercular 
meningitis. Repeated lumbar punctures will, however, often 
relieve headache and other symptoms of Increased cerebral 
pressure, such as convulsions and twitching. It has no 
effect on the progress of the disease, and Is not Indicated at 
present In this Instance. In spite of the hopeless prognosis, 
he must be nursed and fed as If he were certain to get well. 
If he will not swallow, he must be fed with a tube. Further 
treatment must be symptomatic. 



266 CASE HISTORIES IN PEDIATRICS. 

CASE 73. Marion H., seven months old, was the second 
child of healthy parents. There had been no deaths or 
miscarriages and she had had no known exposure to tuber- 
culosis. She was born at full term, after a normal labor, and 
was normal at birth. She had always been nursed and had 
had no illnesses, except an occasional "cold." She had been 
restless and nervous when awake since April 14, but had 
slept most of the time. She had nursed poorly, but had not 
vomited. Her bowels were constipated. Several stools, 
which were passed after she had taken castor oil, were green- 
ish and contained curds and mucus, but no blood. She had 
had some discharge from the nose and eyes since April 17. 
She had had no convulsions, rigidity or twitching, and had 
not coughed. Her mother thought that she had not been 
feverish. She was admitted to the Infants' Hospital, April 

19. 

Physical Examination. She was well developed and 
nourished, and of good color. Her head was of normal size 
and shape. There was slight craniotabes. The posterior 
fontanelle was not quite closed. The anterior fontanelle 
was five cm. in diameter and bulged markedly. The ear 
drums were normal. There was a purulent discharge from 
the eyes. The pupils were equal and reacted to light, but 
she did not notice. The nares were crusted. She had no 
teeth. The mouth and throat were normal. There was no 
rigidity or tenderness of the neck and no neck sign. There 
was a marked rosary. The heart and lungs were normal. 
The abdomen was sunken but not rigid; nothing abnormal 
was detected in it. The liver was palpable two cm. below 
the costal border in the nipple line. The spleen was not 
palpable. The extremities were normal, except for slight 
enlargement of the epiphyses at the wrists. She held her 
arms a little rigidly. The knee-jerks were equal and lively. 
Kernig's sign was absent, as was the contralateral reflex. 
There was no enlargement of the peripheral lymph nodes and 
no eruption. The rectal temperature was 105° F. ; the pulse, 
130; the respiration, 30. 

The urine was of normal color, clear, acid in reaction and 
contained neither albumin nor sugar. 



SPECIFIC INFECTIOUS DISEASES. 267 

Diagnosis. The history throws but little light upon the 
diagnosis. Otitis media and pyelitis, which should always 
be thought of in infancy when the symptoms are as indefinite 
as in this instance, can be excluded on the normal condition 
of the ears and urine. Pneumonia, which should be con- 
sidered in spite of the absence of cough, can be ruled out 
on the normal condition of the lungs and the fact that the 
respiration is relatively slower than the pulse. The undi- 
gested stools suggest to a certain extent disease of the digestive 
tract. When it is remembered, however, that there are no 
other symptoms of indigestion, that they appeared only after 
a dose of castor oil and that undigested stools are the rule in 
all serious illnesses in infancy, it is evident that the trouble 
must be located elsewhere. The late appearance of the 
discharge from the nose and eyes shows that these organs 
were affected secondarily. 

The craniotabes, the open posterior fontanelle, the large 
size of the anterior fontanelle, the rosary and the enlargement 
of the epiphyses at the wrists are all signs of rickets and have 
no connection with the present illness. The one important 
positive physical sign is the bulging of the anterior fontanelle. 
This shows that there is an increase in the intracranial 
pressure. The normal size and shape of the head and the 
absence of separation of the bones of the cranium show that 
this increase in pressure is not due to chronic internal hydro- 
cephalus and that it is of recent development. For all 
practical purposes, the only cause of an increase of intra- 
cranial pressure sufficient to cause bulging of the anterior 
fontanelle in infancy is meningitis. This sign is, of itself, 
enough to warrant the diagnosis of meningitis, even if all 
other signs of the disease are lacking. A positive diagnosis 
of meningitis is, therefore, justified. The failure to notice 
and the slight rigidity of the arms are corroborative evidence 
of its correctness. 

The meningitis in this instance did not develop in the course 
of any other disease. It is, therefore, almost certainly either 
tubercular or cerebrospinal. It is always difficult, and not 
infrequently impossible, to make a diagnosis on the symp- 
tomatology between these two forms in infancy. The slow 



268 CASE HISTORIES IN PEDIATRICS. 

onset and the absence of marked signs of cerebral irritation 
are somewhat in favor, however, of the tubercular type. A 
lumbar puncture must be done, nevertheless, to settle the 
diagnosis, because of the possibility of cure by the use of the 
antimeningitis serum, if it is caused by the meningococcus. 

A lumbar puncture was done, and 20 cc. of very slightly 
turbid fluid, under moderate pressure, allowed to run off. 
This fluid formed a small fibrin clot and contained 80 cells 
to the cubic mm., 90% of which were mononuclear. No 
organisms were seen in the examination of one slide. (See 
Case 72.) A positive diagnosis of Tubercular Meningitis 
is thus warranted. 

Prognosis. The prognosis is hopeless. (See Cases 72 
and 74.) She probably will not live more than four or five 
days. 

Treatment. The treatment can be only symptomatic. 
(See Cases 72 and 74.) 





Opisthotonos in Meningitis. 



SPECIFIC INFECTIOUS DISEASES. 269 

CASE 74. Bessie M., eighteen months old, was the third 
child of healthy parents. The two older children had died 
in infancy, one of pneumonia, the other of infectious diarrhea. 
There had been no miscarriages. She had not been exposed, 
as far as known, to tuberculosis. She was born at full term, 
after a normal labor, and was normal at birth. She had had 
no illnesses, with the exception of an occasional "cold.'* 
She was still on the breast, but took several feedings daily 
of milk and barley water. There had been no indiscretion 
in diet before the onset of her illness. She had an attack of 
vomiting, followed by a convulsion. May 13. She had vom- 
ited four or five times daily since then, but had had no more 
convulsions. She was stupid after she came out of the con- 
vulsion, however, and had so remained. There had been no 
rigidity, twitching or retraction of the head at any time. She 
had been given nothing but the breast since the onset of her 
illness and had taken this very poorly since May 17. The 
bowels had been somewhat constipated, but the stools were 
well digested. She was admitted to the Infants' Hospital, 
May 20. 

Physical Examination. She had evidently lost much 
weight. She was very pale, with a slight tinge of cyanosis 
about the lips. She lay perfectly limp and almost never 
moved. The anterior fontanelle was two cm. in diameter 
and level. There was no rigidity or retraction of the neck 
and no neck sign. The pupils were widely dilated and re- 
acted but little to light. She did not notice. The ear drums 
were normal, as were the mouth and throat. She had eleven 
teeth. There was no rosary. The heart and lungs were 
normal. The respiration was of the Biot type. The abdo- 
men was much sunken, but not tense. Nothing abnormal 
was detected in it. The liver and spleen were not palpable. 
The extremities were normal. There was no spasm of the 
extremities. She did not respond in any way to the prick 
of a pin. There was, however, probably no paralysis, be- 
cause she sometimes moved both her arms and legs. The 
knee-jerks were absent, as was Kernig's sign and the contra- 
lateral reflex. There was no enlargement of the peripheral 
lymph nodes and no eruption. The vasomotor irritability 



270 CASE HISTORIES IN PEDIATRICS. 

of the skin was, however, much increased. The rectal tem- 
perature was 102° F.; the pulse, 170; the respiration, 50. 

The urine was high in color, acid in reaction, of a specij&c 
gravity of 1030 and contained neither albumin nor sugar. 

The leucocytes numbered 10,000. 

Diagnosis. The sudden onset with vomiting suggests 
acute indigestion. The absence of any indiscretion in diet, 
the persistence of the vomiting in spite of an exclusive diet 
of breast-milk, and the absence of all signs of indigestion in 
the stools are, however, against this diagnosis. So also 
is the stupidity, which is out of proportion to the severity of 
the symptoms of gastric disturbance. The continued vom- 
iting, the constipation and the stupidity are, moreover, con- 
sistent with meningitis. Uremia, which in an older child 
or an adult would also be suggested by these symptoms, is 
very uncommon in infancy and can be excluded at once on 
the normal condition of the urine. The widely dilated pupils, 
the diminution in the reaction of the pupils to light, the 
failure to notice, the Biot type of respiration and the in- 
creased vasomotor irritability of the skin all point strongly 
to meningitis. It is unusual, however, to have spasm, paral- 
ysis, the knee-jerk, Kernig's sign, the neck sign, the contra- 
lateral reflex and bulging of the fontanelle all absent in 
meningitis. The absence of bulging of the fontanelle is espe- 
cially strong evidence against it. The rapid pulse and res- 
piration do not count against it, however, because, contrary 
to the general belief, slowing of the pulse and respiration 
occurs but seldom in meningitis in infancy. While bulging 
of the fontanelle, if acute, is almost certain proof of men- 
ingitis in infancy, the absence of bulging does not rule it 
out, because the intracranial pressure is sometimes not in- 
creased enough to bulge the fontanelle, especially if the 
exudation is markedly purulent or gelatinous. In the so- 
called flaccid type of tubercular meningitis, moreover, 
flaccidity is the most prominent symptom and all signs of 
cerebral irritation are, as in this instance, absent. In the 
absence of all physical signs of any other disease, the diag- 
nosis of meningitis seems justified. The sudden onset points 
to the cerebrospinal type; the absence of leucocytosis, to 



SPECIFIC INFECTIOUS DISEASES. 27 1 

the tubercular form. Flaccidity and the absence of all evi- 
dences of cortical irritation are less unusual in tubercular than 
in cerebrospinal meningitis. A probable diagnosis of Tuber- 
cular Meningitis of the flaccid type seems, therefore, a 
reasonable one. A lumbar puncture should be done, how- 
ever, to confirm the diagnosis (see Cases 72 and 73). 

Lumbar puncture was done and ten cc. of a very slightly 
turbid fluid, under low pressure, allowed to run out. This 
fluid contained eighty cells to the cubic millimeter and formed 
a fine fibrin clot. The cells were all lymphocytes. No organ- 
isms were found on a hasty examination. The diagnosis of 
tubercular meningitis is, therefore, correct. 

Prognosis. The prognosis is hopeless (see Cases 72 and 
73). She probably will not live more than two or three days. 

Treatment. The treatment can be only symptomatic (see 
Cases ^2 and 73). 



272 CASE HISTORIES IN PEDIATRICS. 

CASE 75. Girdham D., three years old, took rather a 
long walk with his mother the afternoon of December 27, 
which was a very cold and windy day. He had sausages for 
supper, which was not an unusual occurrence, and went to 
bed apparently perfectly well. He vomited several times 
during the latter part of the night. A physician who saw him 
the next morning found nothing abnormal on physical 
examination. He cleaned him out with castor oil, gave him 
bicarbonate of soda and limited his diet to broth and albumin 
water. He did not vomit any more, had a comfortable day 
and slept well the night of the 28th. He was a little stupid all 
day on the 29th, but from time to time complained of head- 
ache. In the afternoon the physician found that his neck was 
a little stiff and that his pulse was irregular. The bowels had 
not moved during the day. He was seen in consultation at 
6 P.M. 

Physical Examination. He was well developed and nour- 
ished and of good color. He was somewhat stuporous but, 
when roused, was rational, although irritable. Passive 
movements of the neck were a little limited and caused some 
pain. The neck sign was absent. The membranse tym- 
panorum showed nothing abnormal. The pupils were equal 
and reacted to light. There was no enlargement of the cervical 
lymph nodes. The tongue was moderately coated, the throat 
normal. The heart was normal, except that it was somewhat 
irregular in force and rhythm. The lungs and abdomen 
showed nothing abnormal. The liver and spleen were not 
palpable. The extremities were normal. There was no spasm 
or paralysis; the knee-jerks were equal and normial; Kernig's 
and Babinski's signs were absent; there was no contra- 
lateral reflex. The rectal temperature was 101° F., the pulse 
140. 

Diagnosis. The only conditions to be considered in this 
instance are intestinal toxemia and meningitis. The appear- 
ance of the symptoms of disturbed digestion immediately 
after the taking of improper food, following over-exertion and 
exposure to cold, make toxemia the more probable. The only 
things which really suggest meningitis are the persistence of 
the symptoms after catharsis and limitation of the diet and 



SPECIFIC INFECTIOUS DISEASES. 273 

the slight rigidity of the neck. Disturbances of digestion and 
toxemia not infrequently persist, however, after catharsis 
and star^^ation, and symptoms of meningeal irritation are 
not at all uncommon in intestinal toxemia. The slightly 
stuporous condition, the irritability and the irregularity of 
the pulse are consistent with either condition. The absence 
of all physical signs of meningeal irritation, except the slight 
rigidity of the neck, is strongly against meningitis, but does 
not exclude it, because these symptoms are not infrequently 
lacking for several days, or even longer, after the onset. The 
chances seem very much in favor of intestinal toxemia, but 
there is enough to suggest meningitis to justify a lumbar punc- 
ture for diagnosis. This is a harmless procedure and, now 
that cerebrospinal meningitis can usually be cured by the 
antimeningitis serum, if it is administered early, should be 
done in every case in which there is a reasonable probability 
of meningitis. The sudden onset and rather rapid develop- 
ment of the stuporous condition suggest cerebrospinal 
rather than tubercular meningitis, but they are not in- 
consistent with the tubercular form at this age. 

The fluid obtained by lumbar puncture was under high 
pressure and very turbid. A large fibrin clot formed on 
standing. The fluid contained 2,600 cells per cubic 
millimeter. So many of the cells were broken down that a 
differential count was impossible. There was, however, un- 
doubtedly a large excess of polynuclear cells. Numerous 
Gram-decolorizing diplococci were seen within the cells. 
(See Case 72 for description of the normal cerebrospinal 
fluid and of the fluid in meningitis.) The results of the exami- 
nation of the fluid obtained by lumbar puncture justify, of 
course, an absolute diagnosis of Cerebrospinal Meningitis. 

Prognosis. The chances for recovery, if he is treated with 
the antimeningitis serum, are better than even, because it 
is less than forty-eight hours since the onset, the symptoms 
are comparatively mild and the organisms are all within the 
cells. This latter point shows that nature is making a fairly 
successful struggle against the infection. 

Treatment. Another lumbar puncture must be performed 
as soon as the antimeningitis serum can be secured. All the 



274 CASE HISTORIES IN PEDIATRICS. 

fluid that will run out must be allowed to escape. An equal 
amount of serum must then be introduced through the same 
needle, provided that 30 ccm. or more has run out. If less 
than that has been obtained, 30 ccm. must still be given, un- 
less undue resistance is met in giving this amount. This, or 
a larger dose, according to the amount of fluid which escapes, 
must be repeated daily until no micro-organisms can be 
found in smears made from the fluid. If the temperature 
remains much elevated or the symptoms are not improving, 
the serum treatment must be continued even if the organisms 
have disappeared. Far better results are obtained from good- 
sized doses, frequently repeated, in the beginning, than from 
smaller doses or from the same or larger doses at longer inter- 
vals. Rigidity of the neck alone is not an indication for the 
continuance of the treatment, since rigidity often persists 
well into convalescence. No other treatment, except regula- 
tion of the bowels and of the diet, is indicated in this instance. 



SPECIFIC INFECTIOUS DISEASES. 275 

CASE 76. Timothy D., twelve years old, was the child of 
healthy parents. An uncle had died of pulmonary tubercu- 
losis a year before. He had not lived with him, but had seen 
him repeatedly. He had always been well, except for an 
illness '' similar to the present " a year before. 

He began to be dizzy about August 26, but had no other 
symptoms except constipation. He was first seen by his 
physician September 2. The physical examination and the 
urine then showed nothing abnormal. His bowels were 
thoroughly cleaned out, but the dizziness persisted. Septem- 
ber 6 he began to complain of stiffness in the neck and held 
his head turned to the right. Passive motions were, however, 
but little limited and did not cause pain. The pupils were 
equal and reacted to light. The knee-jerks were equal and 
normal. Kernig's and Babinski*s signs were absent. The 
neck was stiffer September 8 and he began to complain of 
pain in the neck. The pulse also became slow, running be- 
tween 56 and 64. He began to vomit on the 9th and the rigid- 
ity and pain in the neck became much worse. The highest 
temperature up to the morning of the 9th was 99° F. ; that 
morning it was 100° F. The constipation had persisted. He 
was seen in consultation at 4 p.m., September 9. 

Physical Examination. He was well developed and nour- 
ished and of good color. He was perfectly conscious, but 
cried out occasionally from pain in the back of the neck. 
There was no retraction of the neck, but he held his head 
rigidly and turned to the right. All motions of the neck 
caused much pain. The neck sign could not be tested be- 
cause of the rigidity. There was no enlargement of the cervi- 
cal lymph nodes. The tongue was moderately coated; the 
throat normal. The pupils were equal and reacted both to 
light and accommodation. There was no strabismus. The 
membranae tympanorum showed nothing abnormal. The 
heart and lungs were normal. The liver and spleen were not 
palpable. The abdomen was sunken, but not rigid. There 
was no spasm or paralysis of the extremities. The knee-jerks 
were equal and not exaggerated. The cremasteric and ab- 
dominal reflexes were present and not unusually lively. 
There was a marked Kernig's sign on both sides. Babinsld's 



2'](} 



CASE HISTORIES IN PEDIATRICS, 



sign was absent and there was no clonus. There was no dis- 
turbance of sensation. There was no eruption. The taches 
cerebral es were marked. The mouth temperature was ioo° 
F., the pulse 60. 

Diagnosis. There can be no doubt, of course, that he has 
meningitis. The only question is whether it is tubercular or 
cerebrospinal. The known exposure to tuberculosis and the 
slow onset point strongly toward the tubercular form. There 
is nothing in the physical examination which is not consistent 
with either type. The absence of eruptions does not count 
at all against cerebrospinal meningitis since eruptions are 
far more often absent than present in this disease in child- 
hood. It may be remarked in passing that the taches cere- 
brales are of no importance in the diagnosis of meningitis, as 
they are present in all sorts of conditions in childhood. It is 
also worthy of mention that the abdomen, while often sunken 
from the lack of food, is almost never rigid in meningitis. In 
spite of the fact that the disease is almost certainly tubercular, 
a lumbar puncture should be done to make the diagnosis 
certain, because the fact that he has been exposed to tubercu- 
losis does not prove that he has contracted it, and because 
the onset of cerebrospinal meningitis is sometimes slow and, if 
it is cerebrospinal meningitis, the serum treatment may save 
him. 

A lumbar puncture was done at once and 45 ccm. of very 
turbid fluid under moderate pressure was allowed to run out. 
The marked turbidity of the fluid points very strongly to 
cerebrospinal meningitis (see Case 72 for description of the 
cerebrospinal fluid in health and disease), and much over- 
balances the points previously mentioned in favor of tubercu- 
lar meningitis. It justifies a probable diagnosis of Cere- 
brospinal Meningitis and makes it obligatory to treat him 
on this basis without waiting for the results of the examination 
of the fluid. 

Treatment. He should be given 45 ccm. of antimeningitis 
serum, which is equal to the amount of fluid withdrawn, 
through the same needle without withdrawing it. It is un- 
wise to wait for the examination of the fluid, because the 
symptoms are marked and the earlier the serum is given the 



SPECIFIC INFECTIOUS DISEASES. 277 

more likely he is to recover. The serum can do no harm if 
the disease proves to be tubercular and, if it is cerebro- 
spinal, considerable time is saved by not waiting for the ex- 
amination. If the examination of the cerebrospinal fluid 
shows that the trouble really is cerebrospinal meningitis, this, 
or a larger dose, according to the amount of fluid which escapes, 
must be repeated daily until no micro-organisms can be found 
in smears made from the fluid. If the temperature remains 
much elevated or the symptoms are not improving, the 
serum treatment must be continued even if the organisms 
have disappeared. Rigidity of the neck alone is, however, 
not an indication for the continuance of the treatment, since 
rigidity not infrequently persists well into convalescence. 
The withdrawal of the fluid will probably relieve the headache. 
If it does not, an ice cap will probably help it. 

The fluid which was withdrawn showed a small deposit of 
pus and a fibrin clot. Ninety-nine per cent of the cells were 
polynuclear and the diplococcus intracellularis was found 
both within and without the cells, thus verifying the diag- 
nosis of cerebrospinal meningitis. 

Prognosis. The prognosis in this instance is somewhat 
against recovery, because of the long duration of the illness 
before the beginning of treatment. The slow onset and the 
low temperature are, however, points in his favor. 



278 CASE HISTORIES IN PEDIATRICS. 

CASE 77. Simon R., seven years old, was taken suddenly 
sick on the night of March 6 with pain in his head and moder- 
ate fever. He vomited several times during the first twenty- 
four hours, but not afterward. His bowels were opened freely 
with calomel the next day and had moved daily since then. 
The movements were loose, but otherwise normal. He had 
had no cough or nose-bleed. The pain in the head continued 
and the temperature gradually rose to 105° F. He was seen 
in consultation March 10. 

Physical Examination. He was slight but muscular. His 
color was good. There was no eruption. He complained of 
pain all over his head, but of nothing else. He was perfectly 
rational. The pupils were equal and reacted to both light 
and accommodation. There was no strabismus or facial 
paralysis. The ear-drums were normal. The throat showed 
nothing abnormal. The tongue was dry and moderately 
coated. There was no tenderness or rigidity of the neck. 
The heart was normal. Percussion of the lungs showed noth- 
ing abnormal . The respiratory murmur and voice sounds were 
slightly diminished in the lower right back, but not changed 
in character. The level of the abdomen was below that of the 
thorax. The walls were lax and palpation was easy. There 
was no muscular spasm and no tenderness. The liver was not 
palpable. The upper border of the splenic dullness was on 
the eighth rib. The spleen was not palpable. There was 
no spasm or paralysis of the extremities. The knee-jerks 
were lively and equal. Kernig's and Babinski*s signs were 
absent. Sensation to touch was normal. The cervical lymph 
nodes were slightly enlarged. The temperature by mouth 
was 105° F., the pulse no, the respiration 28. 

Diagnosis. Several diseases which it would have been 
necessary to consider at first, because of the acute onset, can 
now be ruled out on the duration of the illness and the 
absence of their typical symptoms and physical signs after 
four days. These are acute indigestion, malaria, scarlet fever, 
tonsillitis and otitis media. The other diseases which are 
suggested by the history are pneumonia, meningitis (more 
probably cerebrospinal than tubercular) and influenza. 

The acute onset with vomiting and the continued high 



SPECIFIC INFECTIOUS DISEASES. 279 

temperature are very characteristic of pneumonia; the head- 
ache is not inconsistent with this diagnosis. Cough, while 
often absent for one or two days, almost always develops, 
however, by the fourth day. The physical signs in the lungs, 
namely, localized diminution of the respiratory murmur and 
voice sounds, are rather characteristic of pneumonia in an 
early stage and are often all that can be found for several days. 
Something more definite would, however, be expected by the 
fourth day. The pulse is slower than would be expected with 
a temperature of 105° F. in pneumonia, and the rate of the 
respiration is not increased out of proportion to that of the 
pulse. This latter point is an extremely important one and, 
when taken in connection with the indefiniteness of the symp- 
toms and physical signs, is sufficient to rule out pneumonia. 

The acute onset, the persistence of the headache and the 
relatively slow pulse and respiration suggest meningitis. The 
clear mind and the absence of all signs of meningeal irritation 
make it, however, extremely improbable. It is certainly not 
probable enough to justify a lumbar puncture for diagnosis. 

The history and lack of physical signs are consistent with 
influenza. The duration of the illness without the develop- 
ment of any catarrhal symptoms, the relatively slight prostra- 
tion and the comparatively slow pulse are, however, against 
it. Influenza seems a more reasonable diagnosis than the 
others, but is far from being satisfactory. 

Is there any other disease which will explain the symptoms 
and physical signs better? There is, and that disease is 
typhoid fever. An acute onset is not unusual in typhoid 
in children. Nose-bleed is relatively infrequent at this 
age. A diffuse headache is characteristic of this disease. 
The spleen is enlarged (the normal upper limit of dullness is 
at the ninth rib). The relatively slow pulse (the normal rate 
at seven years is 90), without any symptoms of increased 
cerebral pressure or meningeal irritation, is almost pathogno- 
monic. It is too early for rose spots, and abdominal symp- 
toms are as often absent as present in typhoid at this age. 
A probable diagnosis of Typhoid Fever seems, therefore, 
justified. 

There are several laboratory tests which may be tried 



28o CASE HISTORIES IN PEDIATRICS. 

which will aid more or less in the diagnosis. Typhoid fever 
has no leucocy tosis ; neither has influenza. A white count 
will be, therefore, of no assistance in differentiating between 
these two diseases. A low white count will, in this instance, 
practically rule out pneumonia and cerebrospinal meningitis. 
Pneumonia, meningitis and typhoid all show the diazo- 
reaction; influenza does not. This test might, therefore, be 
of some assistance in differentiating between typhoid and 
influenza. It is too early to expect a positive Widal reaction, 
and it is hardly worth while to try it at present. A blood 
culture will almost certainly settle the diagnosis at once, as 
they are positive in about ninety per cent of all cases of 
typhoid at this stage. 

Prognosis. The prognosis of typhoid fever at this age is 
very good. He is in good condition and his prognosis is at 
least as good as the average. The duration of the fever will 
probably not be over three weeks. There is very little chance 
of hemorrhage, practically none of perforation. 

Treatment. He must, of course, be kept in bed. The 
author does not believe in a strict milk diet in this disease. 
It does not provide enough calories, is very monotonous and 
tends to cause constipation. He is very sure that patients 
who are fed more liberally are in better condition at the 
end of the disease and that they convalesce more rapidly. 
Broths and beef tea have almost no nutritive value, 
are likely to stir up peristalsis, and should consequently 
be given but sparingly. A suitable diet for this boy is as 
follows : 

Milk, broth, beef tea, barley jelly, rice jelly, farina, milk 
toast, blanc mange, baked custard, junket, ice cream. 

His fever will probably not require much treatment. If 
his temperature is constantly over 104° F., or he is depressed, 
or shows symptoms of disturbance of the nervous system as 
the result of the fever, it will require treatment. Sponge 
baths of alcohol and water, equal parts, at 90° F., every four 
hours, will probably be suflicient to control it. An ice-cap 
for the headache and suds enemata for constipation, if 
present, are all that are necessary at present in addition to 
regulation of the diet and baths. 



SPECIFIC INFECTIOUS DISEASES. 28 1 

CASE 78. Spencer S., eleven months old, was the only 
child of healthy parents. There had been no deaths or mis- 
carriages and he had had no known exposure to tuberculosis. 
There was an epidemic of typhoid fever, caused by infected 
milk, in the Jamaica Plain district of Boston at the time when 
he was taken sick. He lived, however, in the West End. The 
milk which he took was bought at a store in the neighborhood, 
the proprietor of which said that none of his milk came from 
the Jamaica Plain dealers. He had not been away from home 
and there was no typhoid fever in the West End. His milk 
was not heated, he took unboiled water and was given a taste 
of almost everything on the table. 

He vomited several times March 28, but not afterward. 
His appetite became poor and he had two or three green stools, 
containing much mucus, daily. Fever was first noticed 
March 30. He was drowsy most of the time and coughed 
occasionally. He was admitted to the Infants* Hospital, 
April 8. 

Physical Examination. He was well developed and nour- 
ished and of good color. He was conscious, but drowsy. 
The anterior fontanelle was one cm. in diameter and somewhat 
depressed. There was no rigidity of the neck and no neck 
sign. The pupils were equal and reacted to light. The 
mouth and tongue were somewhat dry. The tongue was 
clean. The throat was normal. He had five teeth. There 
was a moderate rosary. The heart was normal. The lungs 
were normal, except for a moderate number of fine, moist 
rales in both backs. The level of the abdomen was that of 
the thorax. There was no spasm or tenderness and nothing 
abnormal was felt. The lower border of the liver was 
palpable two cm. below the costal border in the nipple line. 
The spleen was palpable two cm. below the costal border. 
There were numerous light pink spots, about the size of a pin 
head, scattered over the abdomen. The extremities were 
normal. There was no spasm or paralysis. The knee-jerks 
were equal and rather feeble. Kernig's sign was absent. 
There was no enlargement of the peripheral lymph nodes. 
The rectal temperature was 103.8° F.; the pulse, 138; the 
respiration, 36. 



282 CASE HISTORIES IN PEDIATRICS. 

The urine was high-colored, clear, acid in reaction and con- 
tained no albumin or sugar. 

The leucocytes numbered ii,ooo. No plasmodia malariae 
were seen. 

Diagnosis. The slight disturbance of the digestion, shown 
by the abnormal stools, does not seem sufficient to cause such 
marked constitutional symptoms or such a high temperature. 
Neither does the bronchitis seem severe enough to account 
for them. The absence of leucocytosis is, moreover, much 
against both bronchitis and a primary disturbance of diges- 
tion as the cause. The clean tongue is also against a primary 
disturbance of the digestion. It is evident that they are 
both secondary to some other disease. He is in good condi- 
tion and of good color, the only manifestation of rickets is the 
rosary, and the liver is of normal size. The enlargement of 
the spleen is, therefore, undoubtedly a manifestation of the 
acute illness. The normal pulse-respiration ratio shows that 
he has not pneumonia. The points on which the diagnosis 
must be made are, then, an acute disease with a high tem- 
perature and with the pulse and respiration having the normal 
relation to the temperature and to each other, enlargement 
of the spleen, a macular rash on the abdomen and the absence 
of leucocytosis. Of the acute diseases not accompanied by 
leucocytosis, measles and mumps can be excluded by the 
absence of their characteristic signs, and malaria by the 
absence of plasmodia. Influenza can be ruled out on the en- 
largement of the spleen and the duration of the symptoms. 
Acute miliary tuberculosis is rendered improbable by the 
enlargement of the spleen, the rash, the relatively good gen- 
eral condition and the comparatively slight acceleration of 
the pulse and respiration. The enlargement of the spleen 
and the rash are more consistent with typhoid fever than 
with any other condition. The drowsiness is also character- 
istic of typhoid. The acute onset and the absence of nose- 
bleed do not count against typhoid, because an acute onset 
is the rule in typhoid in infancy and nosebleed is unusual. 
The pulse rate is perhaps increased a little more, relatively to 
the temperature, than would be expected in typhoid. In 
infancy, however, the increase is, as a rule, relatively greater 



SPECIFIC INFECTIOUS DISEASES. 283 

than in older children and adults. The pulse rate does not 
count, therefore, against typhoid. Bronchitis is very common 
in typhoid fever in early life. Its presence in this instance 
is corroborative evidence in favor of typhoid. The diagnosis 
of Typhoid Fever is, therefore, a reasonably certain one. 
A Widal test should be tried. This being the eleventh day 
of the illness, it should be positive, if the trouble really is 
typhoid. The presence of an epidemic of typhoid in the city 
is of interest but, in the absence of any apparent exposure, of 
but little aid in diagnosis. 

Prognosis. Typhoid fever, while a comparatively mild 
disease in childhood, is a more serious matter in infancy and 
is often fatal. He is in good condition, however, has no 
complications, has already been ill eleven days, which is at 
least one-half the usual duration of typhoid in infancy and 
early childhood, and may, therefore, be confidently expected 
to recover. The temperature will probably fall to normal 
by a rapid lysis, without marked remissions, in the course of 
about ten days. 

Treatment. He should be given seven feedings of six 
ounces of a mixture containing 2.50% of fat, 7% of sugar, 
1.50% of proteids and 0.75% of starch. There is no indica- 
tion for the addition of an alkali. He should also be given 
sixteen ounces or more of water during the twenty-four hours. 
He is not depressed by the fever and shows no symptoms of 
disturbance of the nervous system. No treatment is neces- 
sary, therefore, for the fever. There is no indication for the 
administration of drugs. 



284 CASE HISTORIES IN PEDIATRICS.' 

CASE 79. Mary L., six years old, was the third child of 
healthy parents. The other children were alive and well. 
Her mother had had, however, tw^o miscarriages. There was 
no history of tuberculosis in either family or of exposure to 
it. She had had no illnesses, but had been thin and delicate 
during the last two years. 

She began to complain, late in the afternoon of September 
I, of headache, fever and general malaise. These symptoms 
persisted. Her appetite was poor and she vomited consid- 
erable dark-brownish, frothy material several times during 
the next two days. She was given Castoria the first night, 
had four loose, yellowish-brown movements on September 2 
and eight or nine watery, green movements on each of the 
two succeeding days. She had the nosebleed September 5. 
The next day she began to complain of general abdominal 
pain and to hold her right thigh flexed. She was admitted 
to the Children's Hospital, September 7. Her bow^els had 
moved freely that morning after an enema. ^' 

Physical Examination. She w^as poorly developed and 
nourished and moderately pale. She was irritable, restless, 
hyperesthetic and at times slightly delirious, so that but 
little reliance could be placed on her statements as to pain. 
Her face was a little anxious. The pupils were equal and 
reacted to light. There was no rigidity of the neck or neck 
sign. Her tongue was moist and covered with a hea\^ 
white coat. The throat, heart and lungs were normal. The 
liver and spleen were not palpable. The liver flatness ex- 
tended to the costal border. The upper border of splenic 
dullness was on the ninth rib. The abdomen was slightly 
distended and everywhere tympanitic. There was moder- 
ate general tenderness, somewhat more marked in the right 
lower quadrant than elsewhere. An irregularly shaped, mod- 
erately moveable mass, about three cm. wide and eight cm. 
long and moderately tender, was felt in the neighborhood of 
McBurney's point. There was definite muscular spasm in 
this region. There were no evidences of fluid in the abdo- 
men. The right thigh was held about three-quarters flexed 
on the abdomen and extension caused pain. The knee- 
jerks were equal and slightly increased. Kernig's sign was 
absent on the left and could not be determined on the right 



SPECIFIC INFECTIOUS DISEASES. 285 

because of the pain. There was no enlargement of the 
peripheral lymph nodes. Rectal examination showed bulg- 
ing and resistance on the right. There was no eruption. 
The rectal temperature was 105.5° F.; the pulse, 128; the 
respiration, 30. 

The urine was high-colored, acid in reaction, of a specific 
gravity of 1015, and contained a trace of albumin, but no 
sugar. The sediment showed nothing but a few small round 
and squamous cells. 

The leucocytes numbered 13,400. 

The Widal test was negative. 

Diagnosis. The diagnosis in this instance lies between 
tubercular peritonitis, appendicitis and enlargement of the 
mesenteric lymph nodes, presumably as a complication of 
typhoid fever. Abdominal pain, tumor, muscular spasm and 
tenderness and resistance on the right on rectal examination 
are symptoms common to all these diseases and are, there- 
fore, of little importance in differential diagnosis. The 
flexion of the thigh is a secondary symptom and unimpor- 
tant. The onset is not characteristic of any of them and 
can, therefore, be disregarded. The history of failing health 
for two years is suggestive of a tubercular infection, but, 
although making tubercular peritonitis a little more prob- 
able, is of comparatively little importance. The mobility of 
the tumor is much against appendicitis, but perfectly con- 
sistent with tubercular peritonitis and enlargement of the 
mesenteric lymph nodes in typhoid. The increase in the 
number of white cells, although somewhat unusual in tuber- 
cular peritonitis, is not inconsistent with it, while it is not 
great enough to count much against typhoid fever. It counts 
materially against appendicitis, however, because the white 
count in this disease is high unless the system is overwhelmed 
by the toxemia, and in this instance the other symptoms 
show that this is not the case. The temperature is higher 
than would be expected in tubercular peritonitis or appen- 
dicitis, but, while more characteristic of typhoid, is not in- 
consistent with either condition. The increase in the rate 
of the pulse is much less than would be expected in tuber- 
cular peritonitis and appendicitis, when the height of the 
temperature is taken into consideration. A relatively slow 



286 CASE HISTORIES IN PEDIATRICS. 

pulse is, however, characteristic of typhoid fever and is 
strong evidence in favor of this disease. The nosebleed 
points somewhat toward typhoid. The absence of enlarge- 
ment of the spleen and of rose spots and the negative Widal 
test do not count at all against it at this stage. It is possible, 
therefore, to rule out appendicitis on the mobility of the 
tumor, the relatively slight leucocytosis in connection with 
the fairly good general condition and the relatively slow 
pulse. It is more difficult to exclude tubercular peritonitis, 
but the relatively slow pulse is much against it. There is 
nothing inconsistent with enlargement of the mesenteric 
glands in typhoid fever, except the leucocytosis. This is so 
slight, however, that it is not sufficient to rule it out. There 
are, moreover, a number of points in favor of typhoid fever. 
The most important of them is the relatively slow pulse. 
Less important are the nosebleed and the fact that the tem- 
perature is higher and the nervous symptoms more severe 
than would be expected from the local conditions in the 
abdomen. An almost positive diagnosis of Typhoid Fever 
WITH Enlargement of the Mesenteric Glands is, there- 
fore, justified. A blood culture ought to be made to verify 
the diagnosis, as at this time it will almost certainly be posi- 
tive if the disease is typhoid fever. A skin tuberculin test 
will not be of much assistance. A negative result may mean 
either the absence of tuberculosis or an overwhelming infec- 
tion with tuberculosis, while a positive result merely shows 
that there is tuberculosis somewhere, not that the present 
trouble is tuberculosis. 

Prognosis. Her temperature is high and the nervous 
symptoms are moderately severe. A high temperature and 
marked nervous symptoms are, however, of less significance 
in the child than in the adult. Her heart is strong, her lungs 
are clear, the pulse is not unduly rapid, the mortality from 
typhoid fever in early life is very low, the enlargement of the 
mesenteric lymph nodes does not increase the gravity of the 
illness. She may, therefore, be confidently expected to recover. 

Treatment. The enlargement of the lymph nodes calls 
for no especial treatment. The general m.anagement of 
typhoid fever in childhood is described in Case 77. 



SPECIFIC INFECTIOUS DISEASES. 



287 



CASE 80. Althea P., five and one-half months old, was 
the only child of healthy parents and had always been per- 
fectly well. There had been no miscarriages. Her father had 
had a severe " cold " in his throat and nose about two weeks 
before. She had had a " cold in the nose '* for a week, but 
had not appeared sick or feverish. She had taken the breast 
well up to the last two days. The discharge had irritated 
the upper lip a little. There had been no other symptoms. 

Physical Examination. She was well developed and nour- 
ished and of good color. The anterior fontanelle was 3 cm. 
in diameter and level. She showed a slight tendency to keep 
her mouth open. There was a small amount of thin, watery 
discharge from the nose which irritated the upper lip. The 
turbinates were a little swollen and reddened and had a few 
crusts on them. No membrane was seen. The throat was 
perfectly normal. There was no rosary. The heart and lungs 
were normal. The level of the abdomen was that of the 
thorax. It showed nothing abnormal. The liver was palpable 
2 cm. below the costal border in the nipple line. The spleen 
was not palpable. The extremities were normal. There was 
no spasm or paralysis. The knee-jerks were equal and normal. 
Kernig's and Babinski's signs were absent. There was no 
enlargement of the peripheral lymph nodes The rectal 
temperature was 99.2° F. 

Diagnosis. Syphilitic rhinitis can be at once excluded on 
the good family history, the previous good health, the good 
general condition, the history of exposure to her father's 
" cold " and the absence of all other signs of syphilis. The 
only thing to suggest diphtheritic rhinitis is the persistence 
of a watery discharge which irritates the upper lip. The 
absence of constitutional symptoms, fever and enlargement of 
the cervical lymph nodes does not count at all against diph- 
theritic rhinitis, because a persistent, irritating, nasal dis- 
charge without other symptoms is most characteristic of this 
disease in infancy. The chances are, of course, much in 
favor of a simple rhinitis, but the watery, irritating character 
of the discharge is suspicious enough to demand a bacterio- 
logical examination. This was made and an almost pure 
culture of the Klebs-Loeffler bacillus was found, justifying 



288 CASE HISTORIES IN PEDIATRICS^ 

the suspicion of Diphtheritic Rhinitis. The presumption is 
that her father had had diphtheria and that she had caught 
it from him. 

Prognosis. The prognosis is perfectly good. Extension of 
the process is very unusual, even if it is untreated. The 
chief danger is of infection of those about her. 

Treatment. The treatment is the administration of the 
antitoxin of diphtheria. Fifteen hundred units, repeated in 
two days, will probably be sufficient; more must be given if 
the discharge persists. Local treatment is hardly necessary, 
but some simple alkaline solution, dropped in the nose with a 
medicine dropper, every few hours, will probably make her 
more comfortable. She must be isolated until two consecutive 
negative cultures have been obtained from both the nose and 
throat. 



SPECIFIC INFECTIOUS DISEASES. 289 

CASE 81. Martin S., six years old, began to have a loud, 
ringing cough with slight difficulty in breathing during the 
night of May 23. The cough and difficult respiration con- 
tinued without diminution during the 24th. That night the 
difficulty in respiration increased considerably, so that he 
slept but little. He was no better on the morning of the 25th 
and was not able to talk aloud. During the day the difficulty 
in breathing increased very rapidly, so that he had to sit up 
to breathe. He became cyanotic and was unable to take 
nourishment. His temperature during these days had ranged 
from normal to 101° F. Repeated examinations of the throat 
had shown nothing abnormal. He was seen in consultation 
at 7.30 P.M., May 25. 

Physical Examination. He was a large, strong boy. He 
was markedly cyanotic and was sitting up in bed with his 
head stretched forward. The inspiration was noisy. The 
cough was harsh and dry. He was unable to speak above a 
whisper. The cervical lymph nodes were slightly enlarged. 
The tonsils were moderately enlarged and somewhat reddened, 
but there was no exudation upon them. There was no nasal 
discharge. There was sinking in of the supraclavicular spaces, 
of the lower intercostal spaces and of the epigastrium with 
each inspiration. Percussion of the lungs was normal. The 
respiratory murmur was very feeble, but not abnormal in char- 
acter. Very many loud, medium and coarse, moist rales were 
heard over both chests. The rales were alike in both chests 
and both behind and in front. There was nothing abnormal 
about the heart except the rapidity of its action. The 
abdomen was normal. The liver and spleen were not palpable. 
The extremities were not examined. The axillary tempera- 
ture was 101° F., the pulse 150, the respiration 24. 

Diagnosis. The cyanosis and the retraction of the epi- 
gastrium, intercostal and supraclavicular spaces are simply 
manifestations of some obstruction to the entrance of air 
into the lungs and do not indicate where the obstruction is 
located. The head is stretched forward in order to make 
breathing easier by straightening the upper air passages. 
The normal condition of the nose and throat rules out ob- 
struction above the larynx. The signs in the lungs are not 



.290 CASE HISTORIES IN PEDIATRICS. 

sufficient to account for so much cyanosis and retraction. 
The fact that the rales are alike in both chests, both back and 
front, shows, moreover, that they are not made in the bronchi, 
but transmitted from above. The relatively low rate of the 
respiration also shows that the trouble in the lungs is not the 
cause of the cyanosis and retraction. The obstruction must, 
therefore, be situated in the larynx. The noisy inspiration, 
the harsh dry cough and the whispering are all characteristic 
of inflammation of the larynx and corroborative of the 
diagnosis of laryngeal obstruction. 

The next point to be determined is whether the trouble in 
the larynx is catarrhal or diphtheritic. The progressive 
increase in the difficulty in respiration is almost pathognomonic 
of laryngeal diphtheria and entirely different from the course 
of catarrhal laryngitis, in which the obstruction is not con- 
tinuous and progressive, but occurs in paroxysms, being 
worse at night than during the day. The progressive in- 
crease in the symptoms is of itself sufficient to justify the 
diagnosis of Laryngeal Diphtheria. The slight degree of 
the fever is consistent with either condition, but is more 
characteristic of laryngeal diphtheria than of catarrhal 
laryngitis, in w^hich the temperature is usually higher. The 
absence of marked inflammation of the throat and of enlarge- 
ment of the cervical lymph nodes does not count at all against 
laryngeal diphtheria because in primary laryngeal diphtheria 
the throat is usually not involved and, as there is but little 
absorption from the larynx, the lymph nodes are not enlarged. 
It would be criminal, in this instance, to await bacteriological 
verification of the diagnosis. A negative culture, if taken 
from the throat, would not, in fact, invalidate the diagnosis 
of laryngeal diphtheria, because the diphtheria bacilli are 
often absent from the throat when the diphtheritic process 
begins in the larynx. 

Prognosis. The prognosis is practically hopeless without 
intubation, and very grave with intubation unless antitoxin 
is given freely. With intubation and antitoxin the chances 
are in his favor, because he is in good general condition, there 
is no involvement of the throat, practically no septic absorp- 
tion and his heart is strong. 



SPECIFIC INFECTIOUS DISEASES. 29 1 

Treatment. Intubation should be done at once. He 
should be given six thousand units of antitoxin as soon as he 
has quieted down after the intubation. This dose should be 
repeated in eight hours. It is impossible to state in advance 
whether he will need more or not. If his temperature drops 
to normal and the general condition remains good, it will 
probably not be necessary to repeat it. If he coughs up the 
tube and the obstruction does not return, further doses will 
not be needed; otherwise, the antitoxin must be continued, 
perhaps in larger doses. The tube should be removed on the 
third or fourth day. If the obstruction recurs it must be 
replaced. It is far wiser to have some one competent to 
remove and replace the tube in the house as long as the tube 
is in the larynx than to leave him alone, because emergencies, 
such as blocking of the tube and coughing up the tube, are 
liable to occur at any time and, if not met immediately, are 
likely to prove fatal. 

The food should be milk and soft solids, like junket, baked 
custard, ice cream, soft cereals and soft toast. Some children 
take liquids better; some, soft solids. It is impossible to tell 
in advance which he will take better. Most children take 
their food best sitting up. It is wiser, therefore, to try him 
first in this position. If he has trouble in taking it in this way 
he may be able to take it better lying on his back with his 
head lower than his body. If he has much difficulty in taking 
food, it is safer to feed him with a tube introduced through 
the mouth than to persist with other methods. No other 
treatment is indicated at present. 



292 CASE HISTORIES IN PEDIATRICS. 

CASE 82. Isabella C, eight years old, had had measles 
but not scarlet fever. She had been perfectly well during the 
last six months. She slept well the night of November 16, 
ate her usual breakfast, had a normal movement of the bowels 
and went to school apparently in good health. Soon after 
reaching school she began to have a rather severe headache, 
but said nothing about it. When her father went after her at 
noon, he found her very feverish and having a chill. She was 
a little nauseated, complained of headache and was very 
nervous and excited. She was seen at 3 p.m. 

Physical Examination. She was well developed and nour- 
ished and in good general condition. She was very nervous 
and much excited. She complained of feeling cold and of 
headache. The headache was general, not localized. She 
was generally hyperesthetic. There was no rigidity or tender- 
ness of the neck. The pupils were equal and reacted to light. 
The throat was normal. The tongue was slightly coated. 
The membranse tympanorum were normal. The heart and 
lungs were normal. The liver and spleen were not palpable. 
The level of the abdomen was that of the thorax; nothing 
abnormal could be detected in it. There was no spasm or 
paralysis. The knee-jerks were equal and normal; Kernig's 
and Babinski's as well as the neck sign were absent. There 
was no enlargement of the peripheral lymph nodes and no 
eruption. The temperature, by mouth, was 102.8° F., the 
pulse 120, the respiration 35. 

The urine was high in color, acid in reaction, of a specific 
gravity of i ,024, and contained no albumin or sugar. 

The leucocytes numbered 8,100. No plasmodia were seen. 

Diagnosis. This onset is consistent with that of almost 
any of the acute diseases. Certain of them are, however, 
much more probable than the others. These are scarlet 
fever, tonsillitis, influenza and pneumonia. 

Malaria is unlikely in November, and in Boston. It is 
excluded by the absence of plasmodia in the blood. The 
acute onset with headache suggests, to a certain extent, 
meningitis. The hyperesthesia is also rather suggestive. 
The headache and hyperesthesia are, however, equally well 
explained by the temperature. An onset as acute as this is 



SPECIFIC INFECTIOUS DISEASES. 293 

very unusual in tubercular meningitis at this age. The ab- 
sence of all signs of meningeal irritation is also against 
meningitis in any form. The low white count practically 
rules out cerebrospinal meningitis. The absence of sore throat 
at this time, only a few hours after the onset, does not, of 
course, rule out scarlet fever and tonsillitis, but makes them 
somewhat improbable. Neither a rash nor signs in the lungs 
can be expected thus early. The relatively greater increase 
in the rate of the respiration over that of the pulse suggests 
pneumonia, but it is hardly marked enough to be of much 
importance. There is nothing about the onset and symptoms 
inconsistent with influenza, and the absence of physical signs 
is entirely consistent with this disease. The leucocyte count 
is of great assistance in this instance. The low count practi- 
cally rules out scarlet fever, tonsillitis and pneumonia, all of 
which have a marked leucocytosis, and is characteristic of 
influenza, the only other condition to be seriously considered. 
The diagnosis of Influenza seems, therefore, justified. 

Prognosis. There is, naturally, no danger as to life. The 
fever will probably not last many days and she will be able 
to return to school in a week or ten days. 

Treatment. The treatment is simple; a tablespoonful of 
castor oil, laxol or syrup of senna, to empty the bowels; a 
diet of milk, broth and simple starchy foods; an ice-cap for 
the headache; phenacetin and salol, 2 J grains each, every 
three hours, for the headache and general discomfort. 



394 ^^^^ HISTORIES IN PEDIATRICS. 

CASE 83. Leonard O., nineteen months old, had always 
been well. He was in Windham, Conn., on a visit from Sep- 
tember 27 to October 4. He was well while there but was 
severely bitten by mosquitoes. Although the weather was 
cool and he had eaten nothing unusual, he began to have 
loose movements of the bowels October 17. He continued to 
have four or five loose, greenish movements, without curds or 
mucus, daily. His appetite was poor, but he did not vomit. 
He was feverish and sick all day on the 17th, but, aside from 
the loose movements, had no very definite symptoms. He 
was fairly well on the i8th, but was worse again on the 19th. 
When he woke in the morning of the 21st he was cold and 
rather blue and his face looked pinched. Heaters were ap- 
plied and brandy given, and after a few hours he became 
warm again. He then seemed a good deal relaxed, sweat 
quite freely and was depressed all day. He was seen October 
22. He then appeared fairly well, but was quiet and looked 
run down. 

Physical Examination. He was well developed and nour- 
ished, but rather flabby. Pallor was marked. He had twelve 
teeth. The anterior fontanelle was not quite closed. The 
tongue was clean and the throat normal. There was a slight 
rosary. The heart, lungs and abdomen were normal. The 
liver was palpable 3 cm., and the spleen i cm., below the costal 
border. The extremities were normal. There was no spasm 
or paralysis. The knee-jerks were equal and normal. There 
was no enlargement of the peripheral lymph nodes. The 
rectal temperature was normal. A movement which was 
seen was watery, black (presumably from bismuth) and foul, 
but contained no curds or mucus. The urine was pale, 
slightly acid in reaction, of a specific gravity of 1,012 and 
contained no albumin. 

Diagnosis. The periodic increase in the severity of the 
symptoms ought at once to suggest the possibility of malaria, 
in spite of the persistance of the diarrhea. The peculiar 
condition on waking on the 21st, taken in connection with 
the subsequent sweating and depression, makes this diagnosis 
very probable. In fact, this combination is very character- 
istic of the malarial paroxysm in infancy, at which age the 



SPECIFIC INFECTIOUS DISEASES. 295 

chill is usually replaced by cyanosis and cold extremities. 
The sweating in this instance was, however, more pronounced 
than is usual. The marked pallor and the enlargement of 
the spleen are further corroborative evidence. A slight 
enlargement of the spleen, as in this instance, is, however, not 
very uncommon in many acute infections in infancy. The 
enlargement may, moreover, be a chronic one due to the same 
disturbance of nutrition in the past which caused the rickets, 
the results of which are shown in the open fontanelle, the 
slightly delayed dentition and the rosary. Further evidences 
in favor of malaria are the stay in a malarial district and the 
fact that he was bitten by mosquitoes. The time between the 
possible infection and the development of the symptoms 
corresponds, moreover, to the average incubation period of 
malaria. The diagnosis of Malaria is, therefore, justified. 
This diagnosis should, however, never be made positively 
without an examination of the blood. The blood was ex- 
amined in this instance and a single infection with the tertian 
organism found. 

Prognosis. The prognosis is, of course, good. Malaria in 
infancy usually yields very promptly to treatment. 

1 Treatment. The treatment is, of course, the administration 
of quinine. The same rules apply to its use in infancy as in 
later life. Babies will usually take the sulphate of quinine in 
solution by mouth without difficulty and without vomiting. 
If it is vomited it may be given in a suppository. It is rarely 
necessary to give it subcutaneously. This boy should have 

2 grains of the sulphate of quinine by mouth, or 2 J grains by 
rectum, in the late evening of the 22d, 24th, 26th and 28th. 
He ought not to have any paroxysms after the first two doses 
and, theoretically, should be cured by the four doses. In 
order to be doubly safe, however, it will be well to give him 
I grain of sulphate of quinine twice daily for two days, four 
times, at intervals of a week. The saccharated carbonate or 
oxide of iron, in doses of 3 grains, three times daily, after 
eating, will help the anemia. The loose movements are a 
sypmtom of the malaria and will cease with the cure of this 
condition. 



296 



CASE HISTORIES IN PEDIATRICS. 



CASE 84. Ruth A., three and one-half years old, had 
always been well, except for an attack of chicken-pox a year 
previously. She became a little feverish and began to com- 
plain of pain in the left wrist during the afternoon of March 
9. Her temperature that night was 100.5° F. Nothing ab- 
normal was detected about the arm. There was no history 
of any injury. The next morning the temperature was 
102.5° F. and there was more pain and some tenderness, but 
no heat or redness, in the wrist. From this time on the 
temperature and the pulse-rate rose steadily and the pain 
became very severe. Aspirin, in fairly large doses, had had 
no effect on either the pain or the temperature. She had had 
no chills and had not vomited. She was seen in consultation 
late in the afternoon of March 11, forty-eight hours after 
the onset. 

Physical Examination. She was well developed and nour- 
ished and of good color. She was actively delirious but, when 
roused, answered rationally. There was no rigidity or tender- 
ness of the neck and no neck sign. The pupils were equal and 
reacted to light. The throat was normal, the tongue moder- 
ately coated. The heart, lungs and abdomen were normal. 
The liver and spleen were not palpable. The extremities 
were normal, except for the left arm. There was no spasm or 
paralysis. The knee-jerks were equal and normal. Kernig's 
sign was absent. The lymph nodes in the left axilla were 
slightly enlarged and tender; the other peripheral lymph 
nodes were not palpable. There was considerable deep swell- 
ing in the upper two thirds of the left forearm with moderate 
tenderness on pressure, more marked over the radius than over 
the ulna. There was no redness, but some heat. There was 
also a little swelling about the elbow-joint and in the lower 
portion of the upper arm. There was no tenderness over the 
elbow-joint and no evidences of effusion into the joint. 
Passive motions were slightly limited at the elbow, but not 
at the wrist. The rectal temperature was 104° F., the pulse 
160. 

Diagnosis. The diagnosis is not a difficult one. Scurvy 
can be ruled out by the age of the child, the acuteness of the 
onset, the high temperature and the localization of the process 



SPECIFIC INFECTIOUS DISEASES. 297 

in one extremity. Rheumatism is unusual at this age and, as 
a rule, its symptoms are mild. If they are severe, they are 
located in the joints, not in or about the shafts of the bones, 
and several joints are involved at once. Inflammation of 
the superficial tissues can be ruled out by the absence of 
redness and the deepness of the swelling. The trouble must, 
therefore, be located in or about the shafts of the bones, that 
is, it is an osteomyelitis or a periosteitis. It is unimportant 
for practical purposes whether it is a periosteitis, an osteo- 
myelitis or both, for in any case an immediate operation is 
necessary. The swelling shows that there is certainly a 
Periosteitis. In all probability there is an Osteomyelitis 
also, although the absence of extreme localized tenderness is 
somewhat against it. 

Prognosis. The prognosis is very grave. The chances are 
much against recovery even with an immediate operation. 

Treatment. The treatment is immediate operation. 



298 CASE HISTORIES IN PEDIATRICS. 

CASE 85. Lillian H. was nine months old. Her parents 
were well. Two children had died of "cholera infantum" 
and there had been one miscarriage. She was born at full 
term, after a normal labor, was normal at birth and weighed 
six pounds. She was nursed for a month, after which she 
was given modified milk for a month. This did not agree 
with her and she was put on a mixture of two teaspoonfuls 
of condensed milk in eight ounces of water, which was given 
to her whenever she cried. Her digestion had been all right 
since starting the condensed milk and she had gained weight 
fairly well. Swelling and tenderness of the right arm was 
noticed one week and swelling of the left leg three days before 
her admission to the Infants' Hospital. The swelling of both 
arm and leg had increased. They had apparently caused 
considerable pain and had interfered with her sleep. She 
had been feverish, but the temperature had not been taken. 

Physical Examination. She was fairly developed and 
nourished, and of fair color. The anterior fontanelle was 
one cm. in diameter. The tongue was moderately coated. 
There were two teeth. The gums were healthy about them. 
There was an ulcerated area in the median line, at the junc- 
tion of the hard and soft palates, about one-half an inch 
long and one-quarter of an inch wide, with a small super- 
ficial ulceration on each side of the soft palate. The throat, 
heart and lungs were normal. The abdomen was large and 
lax, but otherwise normal. The lower border of the liver 
was palpable two cm. below the costal border in the nipple 
line. The spleen was not palpable. The left arm was nor- 
mal. There was marked swelling of the right hand and 
forearm up to the elbow. The skin was tense and shiny 
and, about the wrist, very red, while in the upper portion it 
was brawny. This swelling was exquisitely tender. Motions 
at the elbow were free and caused but little pain. There was 
no motion at the wrist, but the fingers could be moved a 
little. She lay with the thighs flexed on the abdomen and 
the legs flexed on the thighs. The right leg, however, was 
normal in every way. There was swelling, redness and heat 
over the upper portion of the left leg. Motions at the knee 
caused pain, but were not limited. Motions at the hip and 



SPECIFIC INFECTIOUS DISEASES. 299 

ankle were normal. The rectal temperature was 103° F.; 
the pulse, 160; the respiration, 50. 

The leucocyte count was 48,000. 

Diagnosis. The fact that she has taken nothing but 
condensed milk for seven months, the pain, tenderness and 
swelling in the extremities and the position of the legs suggest 
scurvy. The high temperature, the normal condition of the 
gums, the asymmetrical distribution of the swellings, the 
presence of redness and heat, and the leucocytosis are, 
however, sufficient to rule out this disease. The onset is 
more acute and the superficial evidences of inflammation 
are more marked than is usual in tuberculosis, the swelling 
involves the shafts of the bones rather than the joints and 
two extremities are involved at the same time. Syphilis 
is suggested by the ulcerations in the mouth. They are, 
however, not manifestations of syphilis but simply the result 
of abrasion of the mucous membrane and constitute the 
condition known as Bednar's Aphthae. There are no other 
evidences of syphilis, the temperature is high and the inflam- 
mation is acute. Tuberculosis and syphilis can, therefore, 
be excluded. The leucocytosis, moreover, is much against 
both of these conditions and shows that there is some acute 
inflammatory condition. It is impossible to tell from the 
examination whether the lesions involve the bones of the 
forearm and leg and the wrist joint as well as the periosteum, 
but, as in most cases of inflammation of the bones and joints 
in infancy the original focus is in the bones and extends into 
the joint and to the periosteum, the chances are that in this 
instance there is a Periosteitis and an Osteomyelitis of 
THE Radius, with purulent inflammation of the wrist joint, 
and a Periosteitis and Osteomyelitis of the Tibia. 

Prognosis. The condition is a very serious one. She is 
almost certain to die within a few days of general sepsis, 
unless she is operated upon immediately. If she is, there 
is a fair chance of her recovery. 

Treatment. The treatment is immediate operation. If 
periosteitis is found, the bone should be investigated and the 
medullary canal opened, if necessary. If there is a purulent 
inflammation of the joint, it should be freely opened. 



300 CASE HISTORIES IN PEDIATRICS. 

CASE 86, John D. was the second child. The first child 
was born dead at eight months. There had been no other 
pregnancies. His mother had had no symptoms of syphilis; 
his father was not seen. 

He was born at full term after a normal labor and was 
normal at birth. Dryness of the palms and soles and cracking 
of the lips was noticed when he was two weeks old. A week 
later he began to have trouble in breathing through his nose 
and kept his mouth open. The trouble in breathing steadily 
increased, and when he was four and a half weeks old he 
began to have great difficulty in nursing. He did not vomit. 
The movements from the bowels were normal. He had had 
no fever. He was seen in consultation when five weeks old. 

Physical Examination. He was small but well-nourished. 
There was slight cyanosis of the lips and extremities. The 
anterior fontanelle was 3 cm. in diameter and slightly de- 
pressed. The posterior fontanelle was not quite closed. 
The pupils were equal and reacted to light. There was no 
strabismus. There was a slight purulent discharge from the 
left eye. He lay w^th his head held back. The neck was, 
however, freely moveable. His mouth was open and no air 
entered through the nose. His breathing was irregular, 
difficult and rapid. There was a slight purulent discharge 
from one nostril. The nasal mucous membrane w^as much 
swollen, but no membrane was visible. A probe could be 
passed through both nostrils, but with considerable difficulty; 
its passage caused bleeding. Examination with forceps by a 
nose and throat specialist showed no adenoid growth. There 
was nothing abnormal in the pharynx or in the region of the 
tongue. The lips were cracked. There was retraction of the 
epigastrium with inspiration. The heart and lungs were 
normal, except that at times no respiratory sound could be 
heard. The cry was strong and of normal character, when he 
had breath enough to cry. The abdomen was negative. 
There w^as no enlargement of the liver or spleen. The genitals 
were normal. There were no mucous patches about the anus. 
The extremities were normal except for redness, thickening 
and scaling of the palms and soles. There was no spasm or 
paralysis of the face or of the extremities. The knee-jerks 



SPECIFIC INFECTIOUS DISEASES. 30 1 

were equal and normal. Kernig's sign was absent. There 
was a fine desquamation over the whole body, but no erup- 
tion or scars of any old eruption. The rectal temperature 
was 104° F.; the pulse 160, but fairly strong. The baby 
seemed a good deal exhausted. 

Diagnosis. The purulent discharge from the eye is an 
incidental and unimportant complication. The retraction of 
the epigastrium with inspiration shows that there is an ob- 
struction to the entrance of air somewhere in the respiratory 
tract, but gives no hint as to the location of the obstruction. 
The cyanosis has the same significance. The clear, strong 
cry rules out any obstruction in the larynx. The high tem- 
perature and rapid respiration suggest some pathological 
condition in the lungs. The character of the respiration and 
the absence of physical signs in the lungs rule this out, how- 
ever, and the temperature can be explained equally well by 
toxic absorption from the nose and exhaustion. The negative 
examination of the throat rules out obstruction from adenoids, 
retropharyngeal abscess or malformation. The obstruction 
to the entrance of air must, therefore, be located in the nose. 
The reason that the baby is so much troubled by this obstruc- 
tion is that he has not yet learned to breathe through his 
mouth, and that It prevents him from getting sufficient 
nourishment. It is the nasal obstruction which Is causing 
the serious symptoms in this Instance, and It is this condition 
which must be relieved in order to save the baby's life. The 
retraction of the head is not a sign of meningitis, but merely 
the result of the baby's effort to get more air by straightening 
the upper air passages. 

The possible causes of the nasal obstruction in this instance 
are simple rhinitis, diphtheritic rhinitis and syphilitic rhinitis. 
Any one of them, even the simple rhinitis, can, at this age, 
cause symptoms as serious as those present in this instance. 
Both simple and diphtheritic rhinitis usually have more dis- 
charge than there is in this Instance, and the discharge in 
nasal diphtheria is usually thin and Irritating. The absence 
of visible membrane does not rule out nasal diphtheria, be- 
cause it is often absent or out of sight in this disease. While, 
however, there is nothing about the symptoms or local con- 



302 CASE HISTORIES IN PEDIATRICS. 

ditlons to exclude simple or diphtheritic rhinitis, there is 
much in the history and physical examination which points 
toward syphilitic rhinitis. The previous stillbirth, the ap- 
pearance of dryness of the palms and soles and cracking of the 
lips at two weeks and of nasal obstruction at three weeks, and 
the redness, thickening and scaling of the palms and soles, 
while individually not of much importance, together make 
the diagnosis of Syphilitic Rhinitis practically certain. The 
good health of the mother does not, of course, count in any 
way against the diagnosis of syphilis, because syphilis is 
often transmitted from father to child, although the mother 
shows no signs of the disease. 

Prognosis. The prognosis is very grave, because the cause 
of the obstruction, the syphilis, cannot be removed at once 
and it is doubtful whether the nasal obstruction can be re- 
lieved by local treatment for so long a time as will be required 
to get the syphilis under control. A point in his favor is that 
he is nursed. 

Treatment. The specific treatment of the syphilis must, of 
course, be begun at once. The local treatment of the nasal 
obstruction is, however, of more immediate importance and, 
next to this, the administration of food. A 1-5,000 solution of 
adrenalin chloride is more likely to relieve the nasal obstruc- 
tion than anything else. This is best applied by dropping it 
into the nose with a medicine dropper while the baby is lying 
on its back, so that it can run downward over the nasal 
mucosa. Five drops in each nostril every hour should be 
sufficient. If it is not effective in this strength, it is hardly 
worth while to try stronger solutions. If it does not give 
relief, a 0.5% solution of cocaine may be tried. This must be 
used cautiously, as babies are very easily poisoned by cocaine. 
If these measures are unsuccessful, pieces of rubber tube (a 
catheter is suitable), as large as can be passed into the nose 
and long enough to reach the pharynx, may be inserted into 
both nostrils. 

If the nasal obstruction is relieved by these procedures the 
baby will probably be able to take the breast. If he is not, 
the milk must be withdrawn with a breast pump or squeezed 
out by hand and given to him with a dropper or a Breck 



SPECIFIC INFECTIOUS DISEASES. 303 

feeder, or through a stomach-tube passed through the mouth. 
He ought to get at least sixteen ounces in the twenty-four 
hours; twenty ounces if possible. 

He should be given o. i gram of neosalvarsan in 5 ccm. of 
distilled water, intravenously, as soon as possible. This dose 
should be repeated weekly until all external signs of syphilis 
have disappeared. It will probably be impossible to find a 
vein in an extremity large enough for the injection of the 
neosalvarsan and it will probably be necessary to use one of 
the veins of the scalp or neck. The longitudinal sinus may 
be utilized, if necessary. Inunctions of mercury should be 
begun as soon as the treatment with neosalvarsan has been 
Stopped. A piece of mercury ointment, one-half the strength 
of the official unguentum hydrargyrum, the size of a large 
pea, should be rubbed in daily, the location of the applica- 
tion varying from day to day. It must be remembered in 
this connection that the earliest symptom of mercurial poison- 
ing in infancy is diarrhea, not salivation. The inunctions 
should be continued, with occasional short interruptions, 
for six months. A Wassermann test should then be done. 
If it is positive, the neosalvarsan injections and inunctions 
should be repeated. Whether the Wassermann test was 
positive or not at the end of six months, it should be repeated 
at one year, eighteen months and two years. If it is positive 
at any time, the course of treatment should be repeated. 



304 CASE HISTORIES IN PEDIATRICS. 

CASE 8y. John N. was the only child. His parents said 
that they were and always had been well. There had been-^ 
one previous miscarriage. He was born at full term, after 
a normal labor, and was normal at birth. He had never had 
anything but breast-milk, but had been nursed very irregu- 
larly. He often vomited immediately after nursing and had 
from two to six yellowish-green movements, containing small 
curds, daily. His mother said that he had moved his legs 
and arms freely until he was two weeks old, since when he 
had gradually stopped using them, so that now he almost 
never moved them. He began to scream with pain whenever 
his arms and legs were handled, when he was about four weeks 
old. A nasal discharge appeared when he w^as three weeks 
old and had persisted. He had apparently had no fever 
and had, she thought, gained in weight. The urine had not 
stained the diapers. He was seen at the Infants' Hospital 
when two months old. 

Physical Examination. He was fairly developed and 
nourished, but a little pale. The head was of good shape. 
The anterior fontanelle was one and one-half cm. in diam- 
eter and level. There was no rigidity of the neck. The 
pupils were equal and reacted to light. The mouth and lips 
were healthy. There was an irritating, watery discharge, 
mixed with blood, from the nostrils, which were somewhat 
obstructed. A bacteriological examination of this discharge 
showed no Klebs-Loeffler bacilli. There was no rosary. The 
heart and lungs were normal. There was a small umbilical 
hernia. The abdomen was other^vise normal. The lower 
border of the liver was palpable three cm. below the costal 
border in the nipple line. The spleen was palpable one and 
one-half cm. below the costal border. There was no enlarge- 
ment of the peripheral lymph nodes. The anus and genitals 
were normal. He held his arms closely to his sides, flexed 
to about a right angle at the elbow and with the hands 
sharply flexed at the wrists and turned to the ulnar side. 
The fingers and thumbs were flexed at the metacarpo- 
phalangeal and extended at the phalangeal joints. He was 
able to make all motions with his arms and hands, but they 
caused pain. Passive motions were not limited, but caused 



SPECIFIC INFECTIOUS DISEASES. 305 

much pain. There was considerable swelling at the wrists 
at the level of the epiphyseal line and for a short distance 
above it. There was also a bony swelling in the upper third 
of the left forearm. These swellings were tender, but not 
red or hot. He held his thighs partially flexed on the abdo- 
men with the legs flexed at the knees to about a right angle. 
He could make all motions with his legs, but they were con- 
siderably limited. Passive motions were also limited and 
caused much pain. There was considerable swelling at the 
ankles at the level of the epiphyseal line and for some dis- 
tance above it, as well as of the lower portion of the right 
femur. These swellings were very tender, but not red or 
hot. The knee-jerks and Kernig's sign could not be deter- 
mined, because of the spasm. 

The rectal temperature was 100° F.; the pulse, 120; the 
respiration, 30. 

The urine was pale, clear, acid in reaction, and contained 
no albumin. 

Diagnosis. Peripheral neuritis can be excluded on the 
age of the child, the absence of cause, the spasm of the ex- 
tremities and the presence of the swellings. Spastic diplegia 
can be ruled out on the tenderness and swelling. Scurvy, 
which is strongly suggested by the tenderness and swelling 
of the bones, is rendered very improbable by the age of the 
child and the fact that it has never had anything but breast- 
milk. The location of the swellings is, moreover, not quite 
that of the swellings in scurvy, which are situated over the 
diaphysis and do not extend over the epiphyseal line. The 
age of the baby, the absence of a rosary and the presence of 
pain and tenderness exclude rickets. The history of gradu- 
ally increasing unwillingness to use the extremities, beginning 
at two weeks in a baby previously normal, accompanied 
by pain, tenderness and swelling in the extremities, is very 
characteristic of the acute epiphysitis of congenital syphilis. 
So is the location of the swellings. The position of the 
extremities is that usually assumed in this condition. The 
previous miscarriage, the bloody, irritating nasal discharge 
and the enlargement of the spleen are corroborative evidence 
in favor of this diagnosis. In fact, these things, when taken 



3o6 CASE HISTORIES IN PEDIATRICS. 

together, make the diagnosis of Syphilitic Epiphysitis, 
or Parrot's syphilitic pseudoparalysis, unquestionable. The 
thickening and irregularity at the epiphyseal lines at the 
wrists and ankles, shown in the radiographs taken at this 
time, confirmed this diagnosis, as did the positive Wassermann 
test which was obtained from the blood a few days later. 

Prognosis. The prognosis of this condition, when properly 
treated, is very good. Even if separation of the epiphyses 
has occurred, reunion always takes place and usually without 
any deformity. 

Treatment. He should be given 0.2 gram of neosalvarsan 
in 5 ccm. of distilled water, intravenously, as soon as possible. 
This dose should be repeated weekly until all active evidences 
of syphilis have disappeared. It will probably be impossible 
to find a vein in an extremity large enough for the injection 
of the neosalvarsan and it will probably be necessary to use 
one of the veins of the scalp or neck. The longitudinal 
sinus may be utilized, if necessar}^ Inunctions of mercury 
should be begun as soon as the treatment with neosalvarsan 
has been stopped. A piece of mercury ointment, one-half 
the strength of the official unguentum hydrargyrum, the size 
of a large pea, should be rubbed in daily, the location of the 
application varying from day to day. It must be remem- 
bered in this connection that the earliest symptom of mer- 
curial poisoning in infancy is diarrhea, not salivation. The 
inunctions should be continued, with occasional short in- 
terruptions, for six months. A Wassermann test should 
then be done. If it is positive, the neosalvarsan injections 
and inunctions should be repeated. Whether the Wasser- 
mann test was positive or not at the end of six months, it 
should be repeated at one year, eighteen months and two 
years. If it is positive at any time, the course of treatment 
should be repeated. 

He should be kept on the breast, but should be nursed 
regularly, being given eight feedings in twenty-four hours, 
at two and one-half hour intervals. Boracic acid ointment 
should be applied to the upper lip and liquid albolene dropped 
in the nose every few hours. 



SPECIFIC INFECTIOUS DISEASES. 3O7 

CASE 88. Kenneth B. was admitted to the Children's 
Hospital when six years old. He was the only child. His 
mother had had, however, two miscarriages, four and two 
years before he was born. His father was not seen. His 
mother denied any knowledge of venereal infection and had 
never had any symptoms of it. There was no tuberculosis 
in either family and there had been no known exposure 
to it. 

He was born at full term and was a large, healthy baby. 
He was weaned when two months old and had considerable 
disturbance of the digestion during the first two years. His 
digestion and appetite had been good since that time. He 
had had occasional "colds'* during infancy, but no contin- 
uous snuffles. He had never had a rash or complained of 
sore throat or headache. He had measles when three, and 
whooping-cough when five years old, soon after which he 
was treated at the Massachusetts Charitable Eye and Ear 
Infirmary for interstitial keratitis. He had seen very little 
with his left eye since then. His teeth began to decay soon 
after they appeared. He had lost some weight recently, but 
was active and seemed happy and well. Six months before 
he was seen a lump, the size of a silver dollar, was noticed 
on the right shin. This lump had steadily increased in size. 
A similar swelling appeared on the left leg two months later. 
Neither had been painful, but the one on the right shin had 
been somewhat tender for several weeks. 

Physical Examination. He was fairly developed and nour- 
ished, and somewhat pale. The ear drums were normal. 
There were corneal opacities in both eyes, more marked on 
the left. The tongue was clean, the throat normal. There 
were no mucous patches or rhagades about the mouth. The 
teeth were much decayed. The heart and lungs were normal. 
The abdomen was sunken and lax. Nothing abnormal was 
detected in it. The upper border of the liver flatness was at 
the sixth rib in the nipple line. The lower border was palpable 
one and one-half cm. below the costal border in the same 
line. The spleen was not palpable. The genitals were nor- 
mal. There was a firm thickening over both tibiae ante- 
riorly, giving a sabre-like deformity. The swelling on the 



308 CASE HISTORIES IN PEDIATRICS. 

right was purplish at the summit, somewhat tender and fluc- 
tuated. The extremities were otherwise normal. There was 
no spasm or paralysis. The knee-jerks were equal and nor- 
mal. There were no mucous patches about the anus. There 
were many palpable lymph nodes, the size of peas, in the 
neck, groins and axillae. The epitrochlear glands were the 
size of split peas. There was no eruption and there were no 
scars of old eruptions. The rectal temperature was 99° F. ; 
the pulse, 100; the respiration, 20. 

The urine was of normal color, acid in reaction, of a specific 
gravity of 1024, and contained no albumin or sugar. 

The leucocytes numbered 4200. 

A skin tuberculin test was negative. 

Diagnosis. The lesions which require explanation are the 
swellings over the tibiae, one of which is evidently breaking 
down. The normal temperature, the low white count and 
the absence of pain show that there is no pyogenic infection 
of the bones. The negative tuberculin test excludes tuber- 
culosis as the cause. It would be most unusual to have 
enlargement of both tibiae if the disease was sarcoma, the 
growth of the tumor would have been much more rapid and 
the general condition much more impaired. The only other 
disease which can cause such swellings is syphilis. The 
deformity of the legs is, moreover, the typical one of this 
disease. It is not unusual for gummatous deposits to break 
down. The general enlargement of the peripheral lymph 
nodes, especially of the epitrochlears, is corroborative evi- 
dence in favor of syphilis, as are the corneal scars resulting 
from the interstitial keratitis. The fact that the liver is pal- 
pable is of some, but not of much, importance, because the 
liver is sometimes normally palpable at this age. The his- 
tory of previous miscarriages is confirmatory evidence of 
syphilis. So also are the decayed teeth, in that they show 
an early disturbance of the nutrition. A positive diagnosis of 
Syphilitic Osteoperiosteitis with breaking down of a 
gummatous deposit in the right tibia is, therefore, justified. 

Prognosis. The prognosis as to life is good. The lesion 
of the right tibia will heal under antisyphilitic treatment. 
Some deformity of the tibiae will undoubtedly remain. 




Kenneth B. Case 88. 



SPECIFIC INFECTIOUS DISEASES. 309 

Treatment. The broken down area on the right tibia must 
be opened and, if a sequestrum of bone is found, it must be 
removed. He should be given iodide of potash in as large 
doses as he can bear. He will probably be able to take one 
or two drachms daily without injury. It will also be well 
to start him on a course of inunctions with mercurial oint- 
ment (Unguentum Hydragyri). Bichloride of mercury may 
be substituted for this a little later. If this method of treat- 
ment is not successful, it may be advisable some time in the 
future to give him several injections of neosalvarsan. 



310 CASE HISTORIES IN PEDIATRICS. 

CASE 89. Allen W., sixteen years old, came home from 
boarding-school for the spring vacation, April 11. He had 
never had chicken-pox. He had been successfully vaccinated 
when an infant and again when twelve years old. There had 
been an epidemic of chicken-pox in the school and he had 
been repeatedly exposed, the last time having been on March 
28. There had also been a number of cases of small-pox in 
the city near which the school was situated. He had been 
feeling perfectly well and was sure that there had been no 
eruption on his skin while he was at school. He noticed a 
small blister on his chest when he dressed, April 12. That 
afternoon he began to feel feverish and sick and went to bed. 
His temperature was then 102° F., and there were several 
pimples on his chest. He was seen the next morning. He 
had passed a restless night, because of itching, but was then 
feeling somewhat better. He had some headache, but no 
backache. 

Physical Examination. He was well developed and nour- 
ished and of good color. He was perfectly clear mentally 
and did not appear seriously ill. His trunk was covered 
with papules and vesicles. There were a few on the extremi- 
ties and face and a number on the scalp. The papules did 
not have a shotty feel, the vesicles were all unilocular and 
there were no pustules. There was no eruption in the mouth 
or throat. The tongue was moderately coated. The heart, 
lungs, liver, spleen, abdomen and extremities were normal. 
The temperature in the mouth was 100*^ F. ; the pulse, 96; 
the respiration, 24. 

Diagnosis. The diagnosis lies between a rather severe 
case of chicken-pox and a mild case of small-pox. The known 
exposure to chicken-pox points much more directly to chicken- 
pox than does the possible exposure to small-pox. The two 
successful vaccinations in the past, the last one only four 
years ago, makes small-pox extremely improbable. The 
absence of prodromal symptoms and of an initial rash, the 
appearance of the eruption first on the chest, the greater 
abundance of the eruption on the trunk than elsewhere, the 
absence of a shotty feeling in the papules, the unilocular 
character of the vesicles and the absence of pustules are, 



SPECIFIC INFECTIOUS DISEASES. 3II 

when taken together, sufficient to rule out small-pox. There 
can be no doubt, therefore, that he has a severe case of 
Chicken-pox. 

Prognosis. There is no danger as to life. New crops of 
papules will probably continue to appear for several days. 
The temperature will continue slightly elevated for three or 
four days, but the constitutional symptoms will probably 
cease sooner than that. There will be no scars, if he does 
not scratch. Acute nephritis has been known to develop 
after chicken-pox. This happens so seldom, however, that 
it hardly needs to be considered, even as a possibility. 

Treatment. It will not be necessary to confine his hands, 
because he is old enough to appreciate the harm which he 
may do by scratching. He should be well smeaied, however, 
with some simple ointment, such as unguentum zinci oxidi 
or unguentum aquae rosae, in order to allay the itching. If 
this does not quiet it, a solution of bicarbonate of soda, a 
mixture of equal parts of alcohol and water, or a one per cent 
solution of carbolic acid may be tried. If none of these is 
effectual, a saturated solution of camphor in ether may be 
painted on and allowed to dry. He should be kept in bed 
until his temperature is normal and the constitutional symp- 
toms have ceased. He should be given a rather light diet 
and made to drink considerable water. An occasional dose 
of five or ten grains of a mixture of equal parts of phenacetine 
and salol will probably make him more comfortable. No 
further treatment, unless it be a laxative, is required. 

He should be kept in quarantine until all the scabs have 
come off. It will not be necessary to disinfect his room. 



312 CASE HISTORIES IN PEDIATRICS. 

CASE 90. James T., ten years old, had had none of the 
eruptive diseases. There was an epidemic of measles in 
Boston at the time, and one of the boys at his school had come 
down with it February 13. He began to be feverish during 
the afternoon of February 25, and, as he expressed it, "felt 
bum." His mouth temperature that night was 103° F. It 
dropped to 100° F. the next morning and remained under 
101.5° F. until the afternoon of March i, when it rose to 
102.1° F. He continued to feel miserable, but was up and 
about the room until the afternoon of March i. A loose 
cough, which developed the first night, had persisted. His 
conjunctivae became a little inflamed February 28. His 
appetite was poor, but there had been no disturbance of 
the digestion or other symptoms. He was seen late in the 
afternoon of March i. 

Physical Examination. He was fairly developed and 
nourished and of fair color. He was perfectly clear mentally. 
The conjunctivae were somewhat injected and there was 
slight photophobia. The ear-drums were normal. There 
was a moderate nasal discharge. The whole throat was 
slightly reddened and there was an excessive amount of naso- 
pharyngeal secretion. The tongue was moist and moder- 
ately coated. There were numerous pearly- white spots, the 
size of the shaft of a pin, surrounded by reddened areas, the 
size of the head of a pin or a little larger, on the inside of both 
cheeks. The heart, lungs and abdomen were normal. The 
liver and spleen were not palpable. The extremities were 
normal. There was no spasm or paralysis. The knee-jerks 
were equal and normal. There was no enlargement of the 
peripheral lymph nodes and no eruption. The tempera- 
ture, taken in the mouth, was 102.1° F.; the pulse, 120; the 
respiration, 35. 

The leucocytes numbered 18,000. 

Diagnosis. The sudden onset of an acute disease, associ- 
ated with catarrhal symptoms, in a child known to have been 
exposed to measles twelve days before (this being the usual 
incubation period of measles), is very strong presumptive evi- 
dence in favor of measles. The persistence and increase of 
the catarrhal symptoms, although the temperature is lower 



SPECIFIC INFECTIOUS DISEASES. 313 

than in the beginning, is characteristic of the prodromal 
stage of measles and strengthens the evidence in favor of 
this disease. The slight leucocytosis and the absence of 
symptoms pointing to any other condition are consistent 
with this diagnosis. The spots in the mouth are unques- 
tionably Koplik's spots. These spots are pathognomonic of 
Measles and make the diagnosis certain. This being the 
fifth day of the disease and the temperature having begun to 
go up again, it can be confidently expected that the eruption 
will appear during the night or to-morrow. 

Prognosis, He is in good general condition, his tempera- 
ture is not very high, he is not seriously intoxicated and his 
lungs are clear. He can be expected, therefore, with proper 
care, to recover quickly without complications or sequelae. 
Children of his age are less likely than infants and young 
children to develop severe bronchitis or bronchopneumonia. 

Treatment. He should be kept in bed until his tempera- 
ture is normal, the eruption faded and the signs of bronchitis, 
if he has it, gone. It is not only not necessary but actually 
harmful to shut children with measles up in a hot, close, 
dark room, as was formerly done. The temperature of the 
room should be kept at about 60"^ F. and the v/indows should 
be kept open enough to give an abundance of fresh air. The 
room need not be darkened, unless the light hurts his eyes. 
His diet should be made up chiefly of milk and starchy foods. 
Water should be given freely. He should be given cleansing 
baths regularly, there being no more danger in bathing 
patients with measles than those with other diseases. His 
eyes should be washed frequently with a 4% solution of 
boracic acid. He may be given five grain doses of a mixture 
of equal parts of phenacetine and salol, every three or four 
hours, if he is uncomfortable. If he develops bronchitis, it 
should be treated like any other bronchitis (see Cases 104 and 
105). He should be kept in isolation until the desquamation 
and all catarrhal symptoms have ceased. It will not be neces- 
sary to disinfect the room after his recovery, a thorough 
airing being amply sufficient to prevent contagion. 



314 CASE HISTORIES IX PEDIATRICS. 

Cx\SE 91. Nathaniel T., seven years old, lived in the 
country in an isolated house. He did not go to school and 

had not been away from home for several weeks. He was 
seen in consultation, March 26. 

A boy, eleven years old, came to visit him, March 9, from 
a school in which there was an epidemic of German measles. 
This boy had not had any of the eruptive diseases. Having 
felt perfectly well previously, he vomited March 11, and soon 
after an eruption appeared on the neck and chest. The 
fauces were red and the temperature in the mouth 101° F. 
The eruption gradually extended all over the body and ex- 
tremities and lasted three days. The efflorescence was uni- 
form, but the tongue was not characteristic of scarlet fever. 
There was no enlargement of the cervical lymph nodes. The 
diagnosis of scarlet fever was made and he was isolated. He 
did not desquamate at all, however, and felt perfectly well 
and had no temperature after the second day. 

The tutor, a young man who had had both scarlet fever 
and measles, went to bed feeling perfectly well, March 25. 
He was feverish during the night and on going to bathe in 
the morning noticed a profuse rash on his chest. He was 
seen at noon. His temperature, taken in the mouth, was 
99° F. There was no Koplik's sign. There was a rash over 
the chest, back and arms, resembling closely that of measles, 
but none on the face or legs. His eyelids were not puffy and 
there was no nasal discharge. 

A chambermaid, who had been taking care of the room of 
the first patient, felt feverish the morning of March 26, and 
noticed a rash. She had had no prodromal symptoms. She 
also was seen at noon. Her temperature, taken in the mouth, 
was 100*^ F. Her conjunctivae were a little injected and her 
eyelids a little puffy. She was, however, ver\^ much alarmed 
and had been crying for several hours. There was no rash in 
the throat and no Koplik's sign in the mouth. The papillae 
of the tongue were not enlarged. There was a rash on the 
face, chest and arms which resembled measles, but was rather 
brighter in color and was here and there confluent. There 
was no enlargement of the cervical lymph nodes. 

Nathaniel T. had been perfectly well until March 24, when 



SPECIFIC INFECTIOUS DISEASES. 3I5 

he was a little feverish. The temperature was normal the 
morning of March 25, but there was a fine rash here and there 
on the body. This disappeared during the day, but his 
temperature went up to 101° F. that night. The rash ap- 
peared again the morning of March 26 and the temperature, 
taken in the mouth, was 100° F. He was seen at noon. 

Physical Examination. He was well developed and nour- 
ished and of good color. He seemed to feel perfectly well. 
There was no eruption in the throat and no Koplik's sign in 
the mouth. The tongue was slightly coated, but the papillae 
were not enlarged. He had no cough or nasal discharge and 
the conjunctivae were not inflamed. There was no enlarge- 
ment of the cervical lymph nodes. The heart, lungs, liver, 
spleen, abdomen and extremities were normal, as were the 
deep reflexes. There were a few light-pinkish papules, about 
the size of the head of a pin or a little larger, scattered over 
the body and arms. There was no eruption on the face or 
legs. His mouth temperature was 99.6° F. 

Diagnosis. It is evident that the last three patients have 
the same disease. It is also evident, from the fact that the 
onset in all occurred within a period of forty-eight hours, 
that they must have contracted it from the same source. It 
seems reasonable to suppose that the visitor was this source 
and that he also has the same disease. The period of incu- 
bation in the last three patients was approximately fourteen 
days. This, of itself, is sufficient to make scarlet fever very 
improbable, the period of incubation in this disease being 
almost never over eight days. The tutor has already had 
scarlet fever, and second attacks of this disease are very 
uncommon. The onset in all of them was comparatively 
mild, none of them have a sore throat, redness of the fauces, 
enlargement of the papillae of the tongue or of the cervical 
lymph nodes, while the eruption does not resemble that 
of scarlet fever. Scarlet fever can, therefore, be positively 
excluded. The diagnosis lies, then, between measles and 
German measles. The period of incubation is consistent with 
either disease. Nathaniel is the only one of the three that 
had any prodromal symptoms, and they were very slight. 
The chambermaid is the only one that has any catarrhal 



3l6 CASE HISTORIES IN PEDIATRICS. 

symptoms, and they are probably the result of crying. None 
of them have any eruption in the throat, and Koplik's sign is 
absent in all. Measles can, therefore, also be excluded. The 
only point against German measles is the absence of enlarge- 
ment of the cervical lymph nodes. This is of very little 
importance in the diagnosis from measles, however, as it is 
often absent in German measles and often present in measles. 
It is very evident, therefore, that Nathaniel has German 
Measles. It is also plain that the visitor had the scarlatini- 
form type of the disease, with an unusually acute onset, and 
that he brought the disease with him from school. 

Prognosis. There is, of course, no danger to life. He will 
probably not feel any sicker than he does to-day. The rash 
will almost certainly be gone within three days and there will 
be no desquamation. 

Treatment. It will be wise to keep him in bed and on 
a rather light diet until his temperature has reached normal 
and the rash has faded. No other treatment is necessary. 
German measles is said to be contagious for three weeks 
from the onset of symptoms. There is, however, apparently 
very little real basis for this statement. It v/ill probably 
not be necessary, therefore, to keep him in isolation more 
than a week after the disappearance of the rash. 



SPECIFIC INFECTIOUS DISEASES. 317 

CASE 92. Mary M., seven years old, had always been 
well, except for frequent attacks of acute gastric indigestion 
as the result of indiscretions in diet. She had never had any 
eruption in these attacks. She had been a little out of sorts 
and had complained of a sore throat for two days, but had 
been to school in spite of it. She had not vomited and had 
eaten nothing unusual. She was seen early in the morning 
of the third day. 

Physical Examination. She was well developed and nour- 
ished, and did not look or act especially sick. Her cheeks 
were somewhat flushed. Her tongue was covered with a 
slight, white coat, except at the tip and edges, which were 
clean. The papillae were somewhat enlarged and showed 
distinctly through the coating. The tonsils were moderately 
enlarged, but there was no exudation on them. The whole 
throat was bright red and it could be seen that on the soft 
palate this redness was due to a large number of very fine, 
bright red spots. The heart, lungs, abdomen and extremities 
were normal. There v/as no spasm or paralysis. The knee- 
jerks were equal and normal. There was no enlargement of 
the peripheral lymph nodes. There was a bright red rash 
over the front of the neck and the whole trunk. It extended 
on to the upper arms and downward over the anterior surface 
of the thighs. It was most marked in the folds of the axillae 
and groins. It was found on close inspection to be made 
up of minute red spots, corresponding to the papillae of the 
skin, with normal skin between them. It did not itch. The 
temperature, taken in the mouth, was 102° F. ; the pulse, 
112; the respiration, 24. 

Diagnosis. The only diseases which need to be considered 
in this instance are erythema from indigestion or food poison- 
ing, German measles and scarlet fever. Erythema can be 
ruled out on the absence of all signs of indigestion and of any 
indiscretion in diet, the eruption in the throat and the en- 
largement of the papillae of the tongue. The peculiar dis- 
tribution of the rash and the greater intensity of the eruption 
in the folds of the axillae and groins are also against it. Ger- 
man measles can be excluded on the eruption in the throat 
and the enlargement of the papillae of the tongue, although 



31 8 CASE HISTORIES IN PEDIATRICS. 

the mildness of the onset and the constitutional symptoms 
suggest it. The diagnosis of Scarlet Fever by exclusion is, 
therefore, justified. The eruption in the throat, the enlarge- 
ment of the papillae of the tongue, the distribution of the rash, 
its peculiar characteristics and the greater intensity of the 
eruption in the folds of the skin make up a symptom-complex, 
moreover, which is characteristic of scarlet fever and which 
is presented by no other disease. 

Prognosis. She has a very mild type of the disease. The 
tonsils are but little enlarged, there is no exudation in the 
throat and the cervical lymph nodes are not enlarged, 
although this is the third day of the disease. The chances 
of any severe infection of the throat and cervical lymph 
nodes are, therefore, small. Acute nephritis very seldom 
develops, if patients are properly fed and protected. She 
will be. Inflammation of the heart and joints sometimes 
occurs. There is no way of avoiding these complications. 
Fortunately, however, they are comparatively infrequent. 
She can be expected, therefore, to recover quickly without 
complications. 

Treatment. She must be put to bed and kept there until 
desquamation has ceased. The temperature of the room 
should be kept between 60° F. and 64° F. Her diet should 
be so regulated as to provide a sufficient number of calories 
and at the same time throw as little work as possible on the 
kidneys, that is, on exactly the same lines as in acute ne- 
phritis (see Case 137) in order to prevent its development. 
She should drink a large amount of water in order to dilute 
as much as possible the products of metabolism which are 
eliminated by the kidneys. She should take at least a quart 
of water daily in addition to the liquid which she gets in her 
food. Her throat should be sprayed frequently w^ith some 
mild alkaline wash, like the liquor antisepticus alkalinus. 
She should be given a cleansing bath daily, after which she 
should be anointed freely with vaseline or lanoline. She will 
require no other treatment, unless it be for the relief of 
symptoms like constipation or sleeplessness. 

She must be isolated with her attendant until desquama- 
tion and all catarrhal symptoms and discharges, if any de- 



SPECIFIC INFECTIOUS DISEASES. 319 

velop, have ceased. If desquamation does not appear at 
the usual time, she must be isolated for three weeks. If it 
does not appear before this, it is safe to assume that it will 
not later. Nothing that has not been previously disinfected 
should go out of her room. All scraps of food and other 
small articles, such as pieces of gauze or muslin used in place 
of handkerchiefs, that can be disposed of in the room should 
be destroyed there. When she has ceased desquamating she 
should be given a disinfecting bath in her room, step out of 
the door into a clean blanket and dress elsewhere in her 
clean clothes. 



320 CASE HISTORIES IN PEDIATRICS. 

CASE 93. Gertrude W., twelve years old, was the only 
child of healthy parents. There was, however, a marked tend- 
ency to nephritis and an excess of uric acid in the urine in 
both families. She had always been well, except for measles, 
complicated by nephritis, when she was six years old. She 
had the family tendency to an excess of uric acid in the urine, 
however, and had to take large amounts of water in order to 
keep well. 

She had a chill and vomited early in the morning of No- 
vember 23. The vomiting continued all day. The temper- 
ature rose quickly to 104° F. and had ranged between 104° F. 
and 105° F. since that time. The throat became sore during 
the day. An urticarial eruption appeared during the morning 
of November 24 and had come and gone since then. The 
typical rash of scarlet fever developed in addition during the 
morning of November 25. The vomiting began again and had 
persisted. The bowels were thoroughly moved by calomel 
during the day. She passed urine freely up to 10 a.m., 
November 25. Nine ounces were obtained by a catheter 
at 3 A.M., November 26. This urine was black, of a specific 
gravity of 1025, and contained a large trace of albumin. 
The sediment, which was very heavy, contained a little 
normal blood, very many dark-brown, cast-like bodies and 
much granular detritus. Her pulse ran about 120 and was 
of good character up to the afternoon of November 25. 
Since then it had varied betw^een 130 and 150 and had been 
feeble. She was seen in consultation at 9 a.m., November 26. 

Physical Examination. She was an unusually large, well 
developed girl. She was very drowsy, but was conscious 
when roused. The tongue was very red and dry; the papillae 
were much enlarged. The whole throat was a brilliant red. 
The tonsils were considerably enlarged, but there was no exu- 
dation on them. The cervical lymph nodes were not enlarged. 
The cardiac impulse was somewhat feeble and diffuse. The 
upper border of the cardiac dullness was at the upper border 
of the third rib, the right border three and one-half cm. to 
the right, and the left eight and one-half cm. to the left of 
the median line. The action was slightly irregular and the 
first sound a little weak. There were no murmurs. The 



SPECIFIC INFECTIOUS DISEASES. 321 

lungs and abdomen were normal. The liver and spleen were 
not palpable. There was no dullness over the pubes and the 
bladder could not be felt. The extremities were normal. 
There was no spasm or paralysis. The knee-jerks were equal 
and normal. There was a typical scarlet fever rash on the 
face, neck and chest, with a characteristic white line about 
the mouth. There were also many large and small blotchy, 
erythematous areas, in many places somewhat elevated above 
the surface, scattered over the trunk and extremities. The 
hands and feet were slightly cyanotic. The axillary tem- 
perature was 105° F. ; the pulse, 140; the respiration, 35. 

Diagnosis. She undoubtedly has a very malignant type 
of Scarlet Fever. Myocarditis and acute nephritis have 
already developed. 

Prognosis. The infection is such a virulent one, as is 
shown by the early development of myocarditis and ne- 
phritis, that her chances of recovery are very slight. The 
family tendency to nephritis and uric aciduria, already mani- 
fested in her in the past, makes the outlook still more unfa- 
vorable. She will probably not live more than forty-eight 
hours. 

Treatment. She should, of course, be isolated and the 
usual precautions necessary in the treatment of scarlet fever 
taken (see Case 92). It is very hard to know just how to 
treat her. It will be unwise to attempt to reduce the tem- 
perature by the use of cold externally, because of the danger 
of increasing the congestion of the kidneys. An ice cap will, 
however, probably <io no harm in this way and may perhaps 
reduce the temperature a little. She should have an abun- 
dance of fresh, cool air to breathe to stimulate the vaso-motor 
system, but must at the same time be well protected. Warm 
baths should be tried with the hope of relieving the kidneys 
by inducing sweating. The danger of increasing the tem- 
perature in this way must, however, be borne in mind. Hot 
air baths are contraindicated on this account. Her bowels 
must be freely opened, also with the object of relieving the 
kidneys. Epsom salts, in doses of one-half an ounce, will 
do this most satisfactorily, if they are not vomited. If they 
are, compound jalap powder in doses of thirty grains, or 



322 CASE HISTORIES IN PEDIATRICS. 

trituration of eiaterin in doses of one-half of a grain, may be 
tried. Water is, on general principles, contraindicated by 
the acute congestion of the kidneys (see Case 137). She has 
a tendency to uric aciduria when well, however, and in health 
requires large quantities of water. It will be well, therefore, 
to allow her a pint of water in the twenty-four hours. Food 
should be stopped entirely for the next twenty-four or forty- 
eight hours. Little can be expected from cardiac tonics or 
stimulants, because the weakness of the heart is due to myo- 
carditis. The cardiac tonics are, moreover, contraindicated 
by the acute congestion of the kidneys. It will be wise, 
however, to give her one-sixtieth of a grain of strychnia every 
three hours, and caffeine-sodium benzoate, in doses of one 
grain, from time to time, if necessary. 



SPECIFIC INFECTIOUS DISEASES. 323 

CASE 94. Charles T., eleven years old, had never had 
the mumps, but had been exposed to them at school three 
weeks before. He went to bed feeling perfectly well, but 
was waked up several times in the night by pain in his face. 
He found in the morning that his face was swollen and some- 
what painful and that it hurt him to open his mouth and 
chew. He did not feel sick in other ways. He was seen at 
ten in the morning. 

Physical Examination. He was a large, strong boy in very 
good condition. His cheeks were a little flushed. There 
was a diffuse swelling on the left side of the face extending 
upward in front of the ear, forward to the beginning of the 
zygomatic arch, downward to a little below the angle of 
the jaw, backward to the sternocleidomastoid muscle and 
upward behind the ear. This swelling was moderately ten- 
der, but was not red and did not fluctuate. There was a 
similar swelling over the ramus of the lower jaw on the right. 
The mouth was somewhat dry and the tongue slightly coated. 
There was reddening and swelling about the mouths of 
Stenson's ducts. The throat was normal. The heart, lungs, 
abdomen, external genitals and extremities were normal. 
The liver and spleen were not palpable. The temperature 
in the mouth was 99.4° F. 

Diagnosis. The only diseases which need to be considered 
are cervical adenitis and mumps. The presumption is that 
he has mumps, because the swelling appeared exactly three 
weeks after the known exposure to mumps, that is, at the 
end of the usual period of incubation. The sudden appear- 
ance of the swelling without any previous inflammation of 
the throat or mouth is characteristic of mumps. Cervical 
adenitis develops more slowly and is always preceded by 
some inflammatory condition in the mouth or throat. The 
position of the tumor is that of the parotid gland. The 
swelling in cervical adenitis does not extend on to the face 
or around the ear, but is all behind the jaw. The dryness of 
the mouth and the reddening and swelling about the open- 
ings of Stenson's ducts are also characteristic of mumps 
and do not occur in cervical adenitis. The disease is, 
therefore, certainly Mumps. 



324 CASE HISTORIES IN PEDIATRICS. 

Prognosis. There is no danger as to life. The swelling 
on the right side will increase for a time, but that on both 
sides will probably be gone in a week. The constitutional 
symptoms will not last more than three or four days. The 
submaxillary glands may also be involved, but the chances 
are that they will not. It is possible that orchitis may de- 
velop in the course of ten days or two weeks, but very improb- 
able, as this complication is very unusual in children under 
twelve years of age. Acute nephritis, endocarditis, permanent 
deafness and suppuration of the parotid gland have been 
known to develop as sequelae of mumps, but they occur so 
seldom that they hardly need to be taken into consideration. 

Treatment. He should stay in bed until the swellings have 
subsided, and, on account of the danger of the development 
of orchitis, should be very careful about exposure for at least 
three weeks. Heat applied externally by means of a poultice, 
an electric heating pad or a hot-water bag, will probably make 
him more comfortable. His mouth should be rinsed several 
times daily with some simple alkaline wash, like the liquor 
antisepticus alkalinus. He may have five grains of a mixture 
of equal parts of phenacetine and salol, every three hours, 
if his head aches or he is generally uncomfortable. He may 
have anything within reason to eat that he is able to take 
without discomfort. He should keep away during the next 
four weeks from people who have not had the mumps. It 
will not be necessary to disinfect his room. 



SPECIFIC INFECTIOUS DISEASES. 325 

CASE 95. Elmer B., seven years old, had always been 
well, except for occasional "colds" and an attack of chicken- 
pox when he was five years old. There was an epidemic of 
whooping-cough in the town where he lived and there had 
been a number of cases in the school which he attended. He 
began to have a "cold in his head" ten days before he was 
seen. The nasal discharge had diminished, but a cough, 
which developed after two or three days, had persisted. 
Spraying the nose and throat had had no effect on it. It had 
been frequent, short and dry at first, but during the last few 
days he had coughed much less often. The cough had 
become more paroxysmal in character, however, and was 
harder. He had "strangled" quite badly in one attack the 
morning of the day he was seen, and had vomited from cough- 
ing once the day before. His general health had not been 
affected in any way and his appetite and digestion were good. 
He had not whooped. He had been taken out of school 
when the coryza began, but had been allowed to play and 
sleep in the same room with his younger sister. The object 
of the mother in calling a physician was to find out whether 
or not he had whooping-cough, in order that he might go back 
to school if he had not, and that she might take proper 
measures to protect the younger child, if he had. 

Physical Examination. He was well developed and nour- 
ished, and of good color. He acted perfectly well. There 
was a slight nasal discharge and the pharynx and fauces were 
slightly reddened. The mouth and throat were otherwise 
normal. The heart, lungs, abdomen and extremities were 
normal. The intensity of the respiratory sound was the same 
on both sides. The bronchial voice sound was not heard 
below the seventh cervical spine. The liver and spleen were 
not palpable. The deep reflexes were normal and the pe- 
ripheral lymph nodes were not enlarged. He coughed once 
during the examination. The cough was somewhat paroxys- 
mal in character, but there was no whoop. His temperature, 
taken in the mouth, was 98.4° F. 

Diagnosis. The presence of an epidemic of whooping-cough 
in the town and the fact that there have been a number of 
cases in his school are strong presumptive evidence in favor 



326 CASE HISTORIES IN PEDIATRICS. 

of whooping-cough. The persistence of the cough, in spite of 
the subsidence of the coryza, the slightness of the signs of 
local inflammation in the throat and the absence of all evi- 
dences of bronchitis also points strongly to whooping-cough. 
So does the good general condition and the absence of all 
other symptoms. More important than anything else, how- 
ever, is the change in character of the cough from frequent, 
short and dry to paroxysmal at longer intervals. The vomit- 
ing with the cough is corroborative evidence. The absence 
of a whoop at the end of ten days does not count much 
against whooping-cough, because the whoop in many in- 
stances does not appear for several weeks and sometimes 
even not at all. The slightness of the signs of local irritation 
in the nose and throat and the paroxysmal character of the 
cough seem sufficient to exclude local irritation as the cause. 
A paroxysmal cough, in some instances associated with a 
sound much like a whoop, sometimes develops after influenza. 
The onset, together with the absence of fever and constitu- 
tional symptoms, is, however, sufficient to rule out this 
condition as the cause. Enlargement of the tracheo-bron- 
chial lymph nodes also sometimes causes a paroxysmal cough. 
The absence of the bronchial voice sound below the seventh 
cervical spine and of all evidences of compression from 
enlarged glands excludes this condition. The diagnosis of 
Whooping-cough seems justified, therefore, although he has 
not whooped. It will be well also to examine the blood. The 
finding of a leucocytosis with a relative lymphocytosis will be 
strong confirmatory evidence that he has whooping-cough. 

Prognosis. Judging from the mildness of the symptoms 
and the absence of complications at the end of ten days, he 
will have a mild and short attack. He is, moreover, in good 
general condition and well able to bear the loss of rest and 
food, if it turns out to be a severe one. His circumstances 
are such that he will receive the best of care and be guarded 
against exposure. In all probability, therefore, he will have 
no complications and will pass through the disease without 
being much pulled down by it. 

Treatment. It is very important for him to have an 
abundance of fresh air. There is no reason why he should 



SPECIFIC INFECTIOUS DISEASES. 327 

not be out of doors on pleasant days, even if it is January. 
If the weather is bad, he should play in the house in a room 
with the windows open. If this is not feasible, he should 
change from room to room, each room, as he vacates it, being 
thoroughly aired before he returns to it. The windows should 
also be well open at night. It will not be necessary to change 
his diet, if he does not vomit. If he vomits, he must be given 
another meal to make up for the one he has lost. If the 
vomiting is very frequent, it will be well to feed him every 
three or four hours with comparatively small amounts of those 
foods which leave the stomach quickly, such as milk, raw 
eggs and starches. It will also be well, if the vomiting is 
severe, to try the abdominal belt recommended by Kilmer. 

Local applications to the nose and throat are useless. So 
also are applications to the chest. Inhalations of steam, plain 
or medicated with creosote or similar drugs, may help him 
some, but must not be used to the exclusion of fresh air. 
There are no drugs which limit the course of whooping-cough, 
although there is a considerable number which diminish 
the frequency and severity of the paroxysms to a certain 
extent. To do good, however, they must be pushed up to 
their physiological limit. It seems hardly advisable to use 
them in this instance, therefore, unless the symptoms become 
much more severe than appears probable. If it becomes 
necessary to use any of them, antipyrin, bromoform or the 
bromides are the ones most likely to help him. If his sleep 
is much disturbed, there will be no objection to giving him 
bromide, sulphonal or trional at night. 

The bacillus described by Bordet and Gengou is, without 
much doubt, the cause of whooping-cough. There has been 
much difference of opinion as to the results obtained in the 
treatment of this disease with vaccines prepared from this 
organism. Those obtained recently by the New York City 
Board of Health seem to show, however, that vaccines are 
certainly of considerable value as a prophylactic against 
whooping-cough and that they have some curative action 
after the disease is established. The most favorable results 
have apparently been obtained with polyvalent stock vac- 
cines. It will be advisable, therefore, to give him at once an 



328 CASE HISTORIES IN PEDIATRICS. 

injection of 500 millions of a polyvalent stock vaccine. He 
should be given an injection every second day, the dose 
being doubled at each injection. As large a dose as 10 
billions may be given, if necessary. 

It will be useless to attempt to separate him from his 
sister now, because, as whooping-cough is contagious from 
the appearance of the catarrhal symptoms, she certainly has 
already contracted the disease. She should be given, how- 
ever, a prophylactic injection of 500 millions at once. This 
should be followed by one of one billion and another of two 
billions at three day intervals. He should be kept away 
from other children who have not had whooping-cough until 
he has ceased to whoop and to have definite paroxysms. 



SECTION VI. 

DISEASES OF THE NOSE, THROAT, EARS AND 

LARYNX. 

CASE 96. Virginia G., seven months old, had always had 
a rather feeble digestion, but had recently been doing very 
well on a wet nurse. She had had a " cold in the head '* 
about six weeks before. Soon after recovery from this cold, 
which lasted about a week, she began to have paroxysms of 
cough at night and during her naps. The cough disturbed her 
sleep considerably, but not enough to affect her general con- 
dition. She did not cough much when awake, had no nasal 
discharge or fever, did not snore at night or keep her mouth 
open, and nursed well. 

Physical Examination. She was small but fairly nourished 
and of fair color. The anterior fontanelle was 3 cm. in di- 
ameter and level. There was no snuffles and she kept her 
mouth shut. There were no teeth and the gums were not 
inflamed. The fauces were normal. The membranse tym- 
panorum were normal. There was a slight rosary. The 
heart, lungs and abdomen were normal. The liver was 
palpable 2 cm. below the costal border in the nipple line. 
The spleen was not palpable. The extremities were normal. 
There was no spasm or paralysis; the knee-jerks were equal 
and normal. The cervical lymph nodes were slightly enlarged. 

Diagnosis. The physical examination shows nothing in 
the nose, fauces or chest to account for the cough. There are 
no evidences of otitis media, difficult dentition or disturbance 
of digestion, all of which are sometimes said to be causes of 
reflex cough. A ** nervous " cough probably does not occur 
at this age. Nevertheless, she coughs, and there must be 
some cause for it. This cause will probably be found in the 
nasopharynx, the only region not investigated in the physical 
examination, in spite of the absence of all of the symptoms of 
adenoids common in older children. An examination of the 

329 



330 



CASE HISTORIES IN PEDIATRICS. 



nasopharynx then showed a small amount of soft Adenoids, 
not sufficient to interfere in any way with respiration. Ade- 
noids of this sort, however, if inflamed, will often secrete just 
enough fluid to keep up a constant tickling of the throat and 
cough when the baby is asleep. They are one of the most 
common causes of persistent cough in infancy. 

Prognosis. Removal of the adenoids will stop the cough at 
once. 

Treatment. It is hardly worth while to waste time on 
palliative measures, such as applications to the nasopharynx 
through the nose or mouth, when operation will remove the 
cause at once and hence cure the cough. The operation is a 
simple one and not at all dangerous. There is, moreover, a 
certain amount of risk in leaving the adenoids in situ, because 
they are often the starting point of attacks of rhinitis and 
otitis media and, if they increase in size, will cause obstruction 
to nasal respiration. It is true that they may grow again but, 
if they do, they can be removed again. In the meantime, the 
baby is relieved of its symptoms and freed from the dangers 
to which adenoids expose it. 



NOSE, THROAT, EARS AND LARYNX. 33 1 

CASE 97. John W., twenty-five months old, had always 
had a rather feeble digestion and been backward in develop- 
ment. He had taken less and less solid food during the last 
three months, and for the last month had refused everything 
but liquids. Swallowing seemed to trouble him. He did not 
vomit, had no flatulence or hiccough, and had one small, 
normal movement daily. He had lost considerable weight, 
strength and color during the past month. He had no cough 
or nasal discharge, kept his mouth shut and did not snore at 
night. There had been no fever. 

Physical Examination. He was fair-sized, but flabby and 
pale. The anterior fontanelle was not quite closed. There was 
no nasal discharge. The membranse tympanorum were nor- 
mal. He kept his mouth shut. He had twenty teeth. His 
tongue was clean. The tonsils were somewhat enlarged, but 
not inflamed. There was a slight rosary. The heart and lungs 
were normal. The liver was palpable 2 cm. below the costal 
border in the nipple line. The spleen was not palpable. The 
abdomen was rather large and lax, but otherwise normal. 
The extremities were normal. There was no spasm or paraly- 
sis; the knee-jerks were equal, but rather feeble; there was 
no Kernig's sign. There was no enlargement of the peripheral 
lymph nodes. 

Diagnosis. The rosary shows that he has, or has had, a 
certain amount of rickets. The open fontanelle and large 
abdomen are probably also manifestations of the same dis- 
ease. The flabbiness and pallor are presumably due to an 
insuflicient supply of food. The unwillingness to eat can 
hardly be due to loss of appetite from indigestion because 
there are no other symptoms of indigestion. The enlargement 
of the tonsils seems hardly great enough to interfere mechani- 
cally with the swallowing of solid food. There must be, 
therefore, some other cause. This will probably be found in 
the nasopharynx, as Adenoids in some way often make 
swallowing difficult. Examination of the nasopharynx with 
the finger showed a large mass of firm adenoids situated 
posteriorly, so that they did not interfere with respiration. 
In the absence of any other explanation it is almost certain 
that the adenoids, or the adenoids and the enlarged tonsils 



332 CASE HISTORIES IN PEDIATRICS. 

together, make the swallowing of solid food so uncomfortable 
that he is unwilling to take it. In consequence, he is taking 
an insufficient amount of nourishment and this, in turn, is 
the cause of the progressive failure. 

Prognosis. The removal of the tonsils and adenoids will 
soon be followed by willingness to take solid food. When he 
begins to take a proper amount of nourishment he will soon 
regain his weight, strength and color. 

Treatment. The treatment is the immediate removal of 
the tonsils and adenoids. 



NOSE, THROAT, EARS AND LARYNX. 333 

CASE 98. Mary S., four years old, had had a slight 
nasal discharge and seemed a little feverish all day. She went 
to bed feeling fairly well, however, after eating her usual 
supper. Soon after going to sleep she began to cough from 
time to time, the cough being dry, hard and metallic. About 
nine o'clock her parents heard her breathing noisily and ap- 
parently struggling in her sleep. When they got to her they 
found her sitting up in bed moderately cyanosed and breath- 
ing with much difficulty.- Inspiration was noisy and difficult, 
expiration quiet. She occasionally gave a short, dry, metallic 
cough. She tried to cry out, but could not raise her voice 
above a whisper. At times she clutched at her throat. She 
was seen at 9.30 p.m. 

Physical Examination. She was then breathing quietly 
and her color was good. Her voice was hoarse and her cough 
metallic. There was a slight nasal discharge and the throat 
was a little reddened. The heart, lungs and abdomen were 
normal. The liver and spleen were not palpable. The 
extremities showed nothing abnormal. There was no spasm 
or paralysis. The knee-jerks were equal and lively. Kernig's 
signv^^as absent. There was no enlargement of the peripheral 
lymph nodes. The rectal temperature was 101° F. 

Diagnosis. The only diseases to be considered are laryn- 
geal diphtheria and catarrhal laryngitis with *' spasmodic 
croup." The sudden onset and the short duration of the 
difficulty in respiration positively rule out laryngeal diph- 
theria, in which the onset is slow and the difficulty in respira- 
tion steadily increases without intermissions. The history 
of the nasal discharge during the day and the occurrence of 
the attack in the early evening are also very characteristic of 
'* spasmodic croup." The diagnosis is, therefore. Catarrhal 
Laryngitis with '* spasmodic croup." 

Prognosis. There is, of course, no danger as to life. She 
may or may not have another attack during the night. She 
is likely to have paroxysms the next two or three nights 
unless they are prevented by treatment. Having had ** spas- 
modic croup " once, she is likely to have it for the next few 
years whenever she " catches cold." 

Treatment. This attack is a mild one and does not require 



334 CASE HISTORIES IN PEDIATRICS. 

very active treatment. She should have twenty drops of the 
wine of ipecac and ten drops of paregoric at once, and ten 
drops of the wine of ipecac and five drops of paregoric every 
hour for two or three doses, the object being to relax, but not 
to nauseate her. A " croup kettle " or a dish of boiling water 
in the room will moisten the air and will aid in preventing the 
recurrence of the paroxysms. The temperature of the room 
should be kept at about 64° F. She should be kept in the 
house or, if feverish, in bed for the next three or four days, and 
should be given ten drops of the wine of ipecac every hour, 
beginning at 3 P.M., until bedtime, each afternoon. If the 
paroxysms recur, the treatment recommended for to-night 
should be repeated. 



NOSE, THROAT, EARS AND LARYNX 335 

CASE 99. George T., thirteen months old, began to refuse 
his food February 24. He was feverish and lost weight 
rapidly. He took his food very poorly, but did not vomit and 
his dejections were normal. He had a frequent, painful 
cough. There was no nasal discharge. He was sent to the 
Infants' Hospital February 28 with the diagnosis of bronchitis. 

Physical Examination. He was fairly developed and nour- 
ished. He was pale, but not cyanotic. The general appear- 
ance was that of sepsis. The anterior fontanelle was 3 cm. 
in diameter and level. There was slight puffiness about the 
eyes. There was a considerable general, soft, non-fluctuant 
swelling in the right neck, extending forward from about the 
angle of the jaw to just beyond the median line and downward 
over the clavicle. The alae nasi moved with respiration. 
There was no nasal discharge. He held his head slightly 
extended and kept his mouth open. His throat was full of 
thick mucopurulent material which rendered inspection 
difficult. The right tonsil was moderately enlarged and some- 
what reddened. The respiration was somewhat difficult, but 
not noisy. His cry was clear. There was no retraction of the 
suprasternal, supraclavicular or intercostal spaces. Per- 
cussion of the lungs showed nothing abnormal. Respiration 
was normal in character but diminished in intensity. Numer- 
ous medium and coarse moist r^les were heard throughout 
both chests, both back and front. They were exactly alike 
on both sides. The same sounds were heard under the upper 
part of the sternum and in the middle of the back. The 
abdomen showed nothing abnormal. The liver was just 
palpable in the nipple line. The spleen was not palpable. 
The extremities showed nothing abnormal. There was no 
spasm or paralysis. The knee-jerks were equal and normal. 
There was no Kernig's sign. The rectal temperature was 
104.5° F., the pulse 150, the respiration 35. 

The urine was high in color, acid in reaction, of a specific 
gravity of 1,020, and contained no albumin or sugar. 

The leucocyte count was 30,000. 

Diagnosis. The quiet respiration and the clear cry show 
that there is no trouble in the larynx. The facts that the 
rMes are alike on both sides, both back and front, and that 



336 CASE HISTORIES IN PEDIATRICS. 

the same sounds are heard under the manubrium and in the 
middle of the back show that they are made high up and 
transmitted downward through the bronchi, and not made 
in the chest. This, of course, rules out bronchitis. The high 
temperature, the marked leucocytosis and the general appear- 
ance of sepsis point very strongly to a focus of pus somewhere. 
The soft, non-fluctuant character of the swelling in the neck 
is not consistent with an external abscess. The swelling of 
the tonsils is not as much as would be expected if there was a 
peritonsillar abscess. The unwillingness to take food, the 
puffiness of the eyes, the swelling of the neck, the position of 
the head and the prominence of the tonsil all suggest an 
inflammatory process in the nasopharynx. The collection of 
pus is, therefore, probably in the nasopharynx; that is, there 
is almost certainly a Retropharyngeal Abscess. It is 
noted in the physical examination that, on account of the 
large amount of mucopurulent material in the throat, inspec- 
tion was difficult, and, therefore, presumably unsatisfactory. 
In such cases inspection alone is not sufficient and will often 
fail to reveal serious conditions. The throat should always 
be palpated when inspection is not perfectly satisfactory. 
Palpation, in this instance, showed that the right side of the 
pharynx was filled by a tense, elastic swelling which extended 
downward to the level of the larynx and pushed the tonsil 
forward, thus confirming the diagnosis of retropharyngeal 
abscess. 

Prognosis. The prognosis is grave even if the abscess is 
opened at once, as it should be, because the baby is in poor 
condition and generally septic and may not be able to rally 
even when the source of infection is removed. 

Treatment. The treatment is to open the abscess at once. 
It is not safe to leave it alone, because if it does not rupture of 
itself it interferes with deglutition and respiration and there 
is constant absorption from the abscess, and if it does open 
itself there is danger of suffocation from the sudden dis- 
charge of pus or of a secondary inhalation bronchopneu- 
monia. It is far better to open it through the mouth than 
from the outside. The best way to open it is with a knife, 
guarded except at the point, passed along the finger as a 



NOSE, THROAT, EARS AND LARYNX. 337 

guide. A gag must not be used, because, if the mouth is 
opened too widely, sudden death may result from the pressure 
of the abscess on the pneumogastric nerve. The mouth can 
be held sufficiently wide open with the finger or a tongue 
depressor. The incision is best performed with the patient in 
the upright position. If he is tipped forward the instant the 
incision is made, there is no danger of pus entering the air 
passages. The incision must be opened up widely with the 
finger in order to insure the thorough emptying of the ab- 
scess cavity. The abscess should be squeezed once or twice 
daily with the finger to keep up the drainage and to prevent 
the opening from closing. It will be well to wash out the 
mouth several times daily with some mild alkaline solution. 
If he does not take his food well he must be fed with a tube, 
introduced through the mouth. No stimulation is necessary 
at present. 



338 CASE HISTORIES IN PEDIATRICS. 

CASE 100. Jennie C. was the first child of healthy parents. 
She was born after a normal labor, was nursed for six months 
and did well. When six months old she was said to have had 
pneumonia and some brain trouble with it; at any rate, she 
had convulsions. During and since this illness she had been 
fed on Horlick's Malted Milk, prepared with water. She had 
lost weight, had vomited occasionally and had had a dozen or 
more small, green, watery movements daily. Her nose was 
always stopped up. She kept her mouth open and had con- 
siderable cough. For two weeks she had had many attacks 
daily in which she made a crowing sound, held her breath and 
got black in the face. During the last week several of these 
attacks had terminated in convulsions. She was seen when 
seven months old. 

Physical Examination. She was fairly developed and nour- 
ished. The anterior fontanelle was 5 cm. in diameter, but 
level. There was no craniotabes. The head was of good 
shape. The eyes were rather prominent. She was bright and 
intelligent. The pupils were equal and reacted to light. 
The nares were partially occluded and the mouth was kept 
open. The throat showed nothing abnormal on either in- 
spection or palpation. An attempt to introduce the finger 
into the nasopharynx was unsuccessful. The tongue was 
dry and considerably coated. There were no teeth. There 
was a marked rosary. She held up her head, but was unable 
to sit alone. The heart and lungs were normal. The abdomen 
was rather large and lax. The lower border of the liver was 
palpable 3 cm. below the costal border in the nipple line. 
The spleen was not palpable. There was slight enlargement 
of the epiphyses at the wrists. There was no spasm or paraly- 
sis of the extremities. The knee-jerks were equal and lively. 
There was no Kernig^s sign. During the examination she 
started to cry, then drew in her breath with a crowing noise, 
stopped breathing and became moderately cyanosed. After 
perhaps a minute she began to breathe again and her color 
quickly became good. The mother said that this attack was 
a very mild one and not nearly as severe as many. 

Diagnosis. The condition here is a complicated one. She 
certainly has a chronic disturbance of digestion as the result 



NOSE, THROAT, EARS AND LARYNX. 339 

of improper feeding. She also has a moderate amount of 
rickets. This is proved by the marked rosary and the en- 
largement of the epiphyses at the wrists. Other abnormalities 
which are presumably signs of rickets are the large fontanelle, 
the delayed dentition and the lax abdomen. She has, in 
addition, a chronic rhinitis and presumably adenoids, al- 
though this is not proven, since the attempt to examine the 
nasopharynx was unsuccessful. 

The most important conditions, however, at any rate in the 
opinion of the parents, are the attacks of asphyxia and the 
convulsions. These attacks are so characteristic of the con- 
dition known as Laryngismus Stridulus that a differential 
diagnosis is hardly necessary. The diseases which might 
possibly be confused with it are congenital laryngeal stridor, 
catarrhal laryngitis and laryngeal diphtheria. Congenital 
stridor is present at birth, or develops soon after, is constant 
instead of being paroxysmal and is not accompanied by 
cyanosis. The attacks of difficult respiration in catarrhal 
laryngitis occur less frequently and usually only at night, are 
of longer duration and the breath is never held in them. 
The difficulty with respiration in laryngeal diphtheria is 
constant and progressive and the breath is not held. 

Laryngismus stridulus is not properly a disease, but merely 
a manifestation of the spasmophilic diathesis. In this dis- 
ease there is a marked increase in the nervous excitability, 
which shows itself in various ways, the most characteristic 
manifestations being laryngismus stridulus, tetany and 
convulsions. The convulsions in this instance are undoubt- 
edly merely another manifestation of this diathesis. It is 
almost certainly due to some disturbance in the metabolism 
of calcium. It is uncertain whether this disturbance is or is 
not due to parathyroid insufficiency. There is in all proba- 
bility a deficiency of calcium salts in the blood in the spas- 
mophilic diathesis. It is very possible that her food during 
the past month contained an insufficient amount of calcium, 
or contained it in a form not easily utilized. The rickets is to 
be regarded, therefore, merely as another manifestation of 
the disturbance of nutrition from the unsuitable food and 
not as the cause of the paroxysmal attacks. The rhinitis and 



340 CASE HISTORIES IN PEDIATRICS.' 

adenoids can have no direct etiological connection with the 
attacks, but may possibly act as exciting causes through 
reflex irritation. 

Prognosis. The immediate prognosis of the attacks is, 
on the whole, good, but must be guarded, because babies do 
sometimes die in these attacks. The prognosis in general de- 
pends very largely on whether or not she can get the best 
treatment. If she can, recovery will be rapid; if she cannot, 
the chances are rather against her. 

Treatment. The immediate treatment of an attack is to 
slap her on the back or to dash cold water on her face or chest. 
Artificial respiration is sometimes necessary. Most attacks 
will, however, cease quickly if nothing is done. Bromide of 
soda, in doses of from three to five grains, in an aqueous solu- 
tion, three or four times daily, will tend to diminish the 
frequency of the paroxysms. 

The treatment of the spasmophilic diathesis, and at the 
same time of the disturbed digestion and rickets, consists 
in regulation of the diet. Human milk always quickly re- 
lieves this condition. A purely carbohydrate diet relieves it, 
but much less promptly and is, moreover, not suitable for a 
baby of this age. A return to cow's milk in any form, at any 
rate imtil a considerable time has elapsed, almost invariably 
causes a return of the symptoms. The only rational food for 
this baby is, therefore, human milk. If she cannot get it she 
must be given a starch and sugar solution for as long a time 
as is possible, due regard being paid to her general condition, 
and then quickly worked on to some form of cow's milk. 

It is possible that the administration of some of the cal- 
cium salts, like the lactate, may do good. Desiccated cal- 
cium chloride, in doses of ten grains, six or seven times daily, 
has been highly recommended. The indications are so doubt- 
ful and the results obtained from the calcium salts have been 
so conflicting, however, that they are hardly worthy of con- 
sideration in comparison with human milk. Parathyroid ex- 
tract, in doses of one twentieth of a grain, or m-ore, three 
times daily, would seem a more rational treatment. The 
results obtained with it thus far, however, have not been 
encouraging. 



NOSE, THROAT, EARS AND LARYNX. 34 1 

CASE 101. Florence F., who was nearly three years old, 
was the first child of healthy parents. She was born at full 
term, after a normal labor, was normal at birth and weighed 
ten pounds. She was nursed for thirteen months and then 
given at once whatever her parents ate. She had been 
perfectly well in spite of this, except for a convulsion, without 
known cause, when she was eighteen months old. She had 
had her adenoids removed when she was two years old. 

She came in from her play about noon, February 14, 
vomited her breakfast and immediately had a severe con- 
vulsion. Her diet was then somewhat restricted, but was 
still too hearty for a child of her age. She had had five 
convulsions since then, one of which was preceded by vomit- 
ing. The bowels moved involuntarily in one of them and 
she slept for a long time after another. The convulsions had 
not occurred at any definite time in relation to the taking of 
food, and no connection between the convulsions and any 
special article of diet could be made out. Her appetite had 
continued good, her bowels had moved regularly and the 
stools had looked well digested. She had complained from 
the first, however, of pain in the abdomen and also of pain 
in the back of the head. She also often put her hands to 
her head. She had slept poorly at night and had been very 
fussy during the day. She was very feverish for several 
days after the first convulsion and again between March 22 
and March 25. She had probably had some fever all the 
time, although her temperature had not been taken. She 
had run about as usual until the morning of the day she was 
seen, when she refused to either walk or stand. She was seen 
March 28. 

Physical Examination. She was fairly developed and 
nourished, and of fair color. She was perfectly clear men- 
tally, but fussy and hard to examine. There was no rigidity 
of the neck or neck sign. She both saw and heard. There 
was no spasm or paralysis of any of the muscles supplied by 
the cranial nerves. There was no coryza and the throat was 
normal. The tongue was slightly coated. The heart and 
lungs were normal. The abdomen was sunken and lax; 
nothing abnormal was detected in it. The liver and spleen 



34^ CASE HISTORIES IN PEDIATRICS. 

were not palpable. She would not stand or walk, but used 
her legs normally when lying down. There was no spasm or 
paralysis of the extremities. The knee-jerks were equal and 
normal. Kernig's and Babinski's signs were absent. There 
was no enlargement of the peripheral lymph nodes. The 
rectal temperature was 100.4° F.; the pulse, 112; the res- 
piration, 24. 

The urine was of normal color, clear, acid in reaction, of 
a specific gravity of 1012 and contained neither albumin nor 
sugar. 

The leucocyte count was 20,000. 

Diagnosis. The improper diet, the association of some of 
the convulsions with vomiting and the pain in the abdomen 
and head point to some disturbance of the digestion as the 
cause of the convulsions. The fever is not inconsistent with 
this supposition. Against this explanation are the good 
appetite, the absence of vomiting except at the time of the 
convulsions, the normal and regular stools, and, to a less 
extent, the leucocytosis. The long continuance of the symp- 
toms without the development of any physical signs of cere- 
bral or meningeal irritation practically excludes all forms of 
meningitis and encephalitis. A cerebral tumor would not be 
accompanied by fever and pain in the abdomen, would not 
be likely to cause a leucocytosis and ought by this time to 
have produced some focal symptoms. Idiopathic epilepsy is 
not accompanied by fever, leucocytosis or pain in the head 
and abdomen. None of these explanations is, therefore, 
satisfactory. The leucocytosis and fever show that there 
must be a focus of inflammation somewhere. The physical 
examination has thus far failed to reveal its location and the 
normal condition of the urine rules out disease of the urinary 
tract. Inflammation of the middle ear is probably the most 
common cause of obscure fever at this age, is often accom- 
panied by marked reflex symptoms and very frequently 
produces no symptoms to draw attention to the ear. It is 
usually preceded or accompanied by some symptoms of 
inflammation of the nose or throat, none of which are present 
in this instance. When this possibility is thought of, how- 
ever, the pain in the head, the putting of the hands to the 



NOSE, THROAT, EARS AND LARYNX. 343 

head, the disturbed sleep and the irritability are found to be 
characteristic of it and to point toward it. The ears ought, 
therefore, to be examined. This was done and both drums 
were found to be red and bulging and the landmarks indis- 
tinguishable. Otitis Media is, therefore, undoubtedly the 
cause of the peculiar symptoms. The convulsions are reflex 
in origin; the pain in the abdomen is a referred pain, or, more 
probably, not in the abdomen at all, but merely a manifesta- 
tion of the child's inability to locate pain. 

Prognosis. The pain, restlessness and irritability will 
almost certainly cease as soon as the ears are opened. The 
temperature will soon drop to normal and there will be no 
recurrence of the convulsions. 

Treatment. The treatment is immediate paracentesis of 
both drums, followed by syringing of the ears with warm 
water, three or four times daily. 



344 CASE HISTORIES IN PEDIATRICS. 

CASE 102. John R., six months old, began to have a 
slight *' cold in the head " February 15, but had no other 
symptoms. Three days later he was taken suddenly sick with 
fever, cough and difficulty in breathing. He lost his appetite, 
but showed no other symptoms of gastro-enteric disturbance. 
Swallowing seemed to cause discomfort. He apparently had 
no pain and did not put his hand to his ear. He was taken to 
a physician, February 21, who found the rectal temperature 
104.2° F., the pulse 160 and the respiration 52. He sent the 
baby to the Infants' Hospital with the diagnosis of pneumonia. 
He was not seen and examined until the next day. 

Physical Examination. He was a large, fat baby. His 
color was good. He took considerable interest in his sur- 
roundings. The alae nasi did not move and the respiration 
was not grunting or painful, even when he cried. The 
anterior fontanelle was 3 cm. in diameter and level. There 
was no tenderness on pressure over the mastoids. There was 
no rigidity of the neck. The pupils were equal and reacted to 
light. There was a slight nasal discharge. The tongue was 
moderately coated. The throat was slightly reddened, but 
otherwise normal. The heart and lungs were normal. The 
liver was palpable^2 cm. below the costal border in the nipple 
line. The spleen was not palpable. The extremities were 
normal. There was no spasm or paralysis. The knee-jerks 
were equal and lively. There was no Kernig's sign. There 
was no enlargement of the peripheral lymph nodes. The 
rectal temperature was 100° F., the pulse 115, the respiration 

38. _ 

The urine was pale, clear, acid in reaction, of a specific 
gravity of 1,012 and contained no albumin. 

Diagnosis. The acute onset with fever, cough and diffi- 
culty in breathing and the relatively greater increase in the 
rate of the respiration over that of the pulse point strongly to 
pneumonia. His general appearance, the absence of motion 
of the alae nasi and of grunting and painful respiration, the 
drop in the temperature and the normal condition of the 
lungs, while they do not exclude pneumonia, make it very 
improbable. Some other cause for the symptoms must be 
sought. The only place which has not been investigated is 



NOSE, THROAT, EARS AND LARYNX. 345 

the ear. The absence of pain, putting the hand to the ear and 
tenderness on pressure over the mastoids, does not count at 
all against otitis media. Pain is often absent in this disease. 
Babies seldom put their hands to their ears when they have 
otitis media and often do under other conditions. Tenderness 
over the mastoids is extremely rare in middle-ear disease at 
this age. Examination of the ears showed marked redness 
and some bulging of the right, and slight reddening of the 
left membrana tympani, showing that the trouble was 
Otitis Media. 

Prognosis. The prognosis is good both as to life and the 
maintenance of normal hearing if the proper treatment is 
carried out. If the ear is opened early and proper drainage 
secured, extension to the mastoid, sinuses or meninges very 
seldom occurs at this age. If the drum is opened before it 
ruptures, it usually heals without a scar and leaves the hear- 
ing unimpaired. 

Treatment. The right drum should be opened at once. 
The left should not be touched at present. Both ears should 
be syringed three or four times daily with warm water. 



346 CASE HISTORIES IN PEDIATRICS. 

CASE 103. Joseph B., twenty- two months old, was seen 
in consultation July 22. He lived in a malarial district. He 
had always been delicate and pale. He had had a cough and 
a slightly elevated temperature since an attack of bronchitis 
in the early spring. He had seemed worse and the tempera- 
ture had been higher and more irregular during the last two 
weeks. He had had a chill the night before, which was fol- 
lowed by a temperature of 105° F. and sweating. His appe- 
tite had been poor, but there had been no symptoms of indi- 
gestion, and the movements had been normal. Nothing 
abnormal had been found on physical examination except 
pallor and a slight enlargement of the spleen. The urine had 
shown nothing abnormal. An almost positive diagnosis of 
malaria had been made on the basis of the chill, fever and 
sweating, the enlargement of the spleen, the pallor and the 
apparent absence of any other cause for the symptoms. 

Physical Examination. He was small and only fairly 
nourished. Pallor was marked. The anterior fontanelle was 
closed. He had twelve teeth. There was a slight nasal dis- 
charge and there was a little mucopurulent secretion in the 
nasopharynx. His tongue was moderately coated. There 
was a slight rosary. The heart and lungs were normal. The 
abdomen was rather large but lax. The liver was palpable 
2 cm. below the costal border in the nipple line. The spleen 
was palpable 3 cm. below the costal border. The extremities 
showed nothing abnormal. There was no spasm or paralysis. 
The knee-jerks were equal and normal. Kernig's sign was 
absent. There was a slight general enlargement of the 
peripheral lymph nodes. 

The urine was pale, clear, slightly acid in reaction, of a 
specific gravity of 1,015 ^^^ contained no albumin or sugar. 
The sediment showed no formed elements. 



Blood. 




Hemoglobin, 


42% 


Red corpuscles, 


4,560,000 


White corpuscles, 


30,000 


Small mononuclears. 


45-5% 


Large mononuclears, 


6.0% 


Polynuclear neutrophils, 


47-5% 


Eosinophils, 


1.0% 



347 

There was much variation in the size and shape of the red 
corpuscles, but no nucleated forms were seen. No plasmodia 
malariae were seen. 

Diagnosis. The leucocytosis and the absence of plasmodia 
at once exclude malaria. The rosary means a slight but 
unimportant amount of rickets. The blood has the character- 
istics of secondary anemia in infancy. The enlargement of 
the spleen is probably due to the same cause as the anemia. 
The continued irregular temperature and the chill suggest 
tuberculosis or confined pus. Tuberculosis at this age is 
rarely accompanied by chills, and it is unusual to have a high, 
irregular temperature without some physical signs of tubercu- 
losis. Tuberculosis is, however, the most probable diagnosis 
unless some other cause for the symptoms can be found. The 
most common locality for confined pus in infancy, when it 
is not discovered on a routine examination, and when the urine 
is normal, is the middle ear. The nasal discharge and the 
mucopurulent secretion in the nasopharynx suggest, in this 
instance, the possibility of an infection of the middle ear. 
An examination of the ears showed bulging and reddening of 
both membranse tympanorum. Paracentesis showed pus in 
both middle ears. The diagnosis is, therefore. Otitis Media. 

Prognosis. The prognosis is good. The temperature will 
gradually work down to normal and the general condition 
improve. There is but little chance of extension to the mas- 
toid cells or to the sinuses. Hearing will probably not be 
impaired. 

Treatment. Now that the ears have been opened, the 
treatment is syringing with warm water, three or four times 
daily, until the discharge has ceased and the incisions have 
healed. 



SECTION vii: 

DISEASES OF THE BRONCHI, LUNGS AND PLEURAE. 

CASE 104. John J., three years old, started in with a 
" cold in his head " and cough, January 10. The nasal dis- 
charge diminished and the cough became drier on the 12th. 
He did not seem at all sick until the 13th. The cough was 
then much more severe and apparently painful. His appe- 
tite was poor and he appeared feverish. 

Physical Examination. He was well developed and nour- 
ished. His cheeks were flushed. There was a slight nasal 
discharge. The ear drums were normal. The whole throat 
was moderately reddened, but there was no enlargement of 
the tonsils and no exudation. His tongue was slightly coated. 
The lungs showed nothing abnormal except a few sibilant and 
sonorous rales scattered throughout both chests, both back 
and front. The heart was normal. The abdomen was normal. 
The liver and spleen were not palpable. The extremities 
were normal. There was no spasm or paralysis. The knee- 
jerks were equal and normal. There was no enlargement of 
the peripheral lymph nodes. The rectal temperature was 
100.8° F., the pulse 132, the respiration 34. 

Diagnosis. The diagnosis is, of course, Bronchitis. 

Prognosis. The prognosis at present is perfectly good. 
The only danger is of a consecutive bronchopneumonia. 
This ought not to develop if he has proper care and treatment. 

Treatment. The treatment of bronchitis depends on the 
stage of the bronchitis and the condition of the bronchial 
mucous membrane. The bronchitis in this instance is in the 
early stage. The bronchial mucous membrane is congested, 
dry, swollen and reddened, and consequently there is but 
little secretion. The object of the treatment at this stage is 
to relax the mucous membrane and in this way increase the 
secretion. The drugs which will do this are the so-called 

349 



350 CASE HISTORIES IN PEDIATRICS. 

'^ sedative " expectorants. These are tartar emetic, apo- 
morphin and ipecac. The only one of these which is safe 
to give to children is ipecac. This may be given as the wine 
or syrup. It should be given in water, not mixed with syrups, 
which are inert and disturb the digestion. The object of the 
ipecac is to cause relaxation of the mucous membrane, not 
nausea or vomiting. From five to ten drops every two hours 
is about the right dose for this boy. The alkalies have some- 
what the same action and may be used instead of ipecac. 
A moist atmosphere also tends to moisten and relax the 
bronchial mucous membrane. It will be well, therefore, to 
have a vessel of boiling water or a " croup-kettle " near him. 

The object of the sedative expectorants is to relax the 
bronchial mucous membrane and in this way to hasten the 
cure of the disease. Their dosage and the length of time that 
they are given must be regulated by the condition in the 
bronchi, as revealed by physical examination. They are not 
given for the symptom, cough, and in using them, therefore, 
the amount of coughing must not be considered. The symp- 
tom, cough, is best controlled by some preparation of opium. 
The safest form of opium for a child is paregoric. This boy 
may have from five to fifteen drops every two or three hours 
for the cough if it is troublesome. This also should be given 
in water, not in syrup. The ipecac and paregoric must not be 
combined in the same prescription, because they are given for 
entirely different purposes, and it is necessary to be able to 
give either one without giving the other. He needs the 
ipecac constantly; he may need the paregoric only occasion- 
ally. 

It will be well to give him a tablespoonful of castor oil, or 
one or two teaspoonfuls of syrup of senna at once. The diet 
should be liquids and soft solids. It will be much wiser for 
him to stay in bed. He should have plenty of fresh air, but 
will probably be more comfortable if the temperature does 
not go below 60° F. 



DISEASES OF THE BRONCHI, LUNGS AND PLEURA. 351 

CASE 105. Henry L., twenty-six months old, had always 
oeen well, except for an occasional slight attack of indigestion. 
He was taken sick, January 16, with fever and cough. His 
temperature had varied between 100° F. and 104° F. ever 
since and the cough had continued. The cough, which was 
at first dry, had, however, become loose. The physician who 
had had charge of him said that he had bronchitis and gave 
him ipecac and inhalations of compound tincture of benzoin. 
He had taken his food poorly, but had not vomited and had 
had normal stools. He was seen at 9 a.m., January 22. 

Physical Examination. He was well developed and nour- 
ished, but a little pale. He was sitting up in bed, playing 
with his toys, but coughed frequently. The cough was loose. 
He had no coryza and his voice was clear. The pharynx was 
slightly reddened. The ear drums were normal. The heart 
was normal. There were a moderate number of medium and 
coarse moist rales on both sides behind and a few in front. 
The lungs were otherwise normal. The abdomen was nega- 
tive and the liver and spleen were not palpable. The ex- 
tremities were normal. The knee-jerks were equal and 
normal. There was no enlargement of the peripheral lymph 
nodes. The rectal temperature was 100° F. ; the pulse, 124; 
the respiration, 40. 

Diagnosis. He has an uncomplicated Bronchitis. 

Prognosis. The prognosis is good, barring the possibility 
of a consecutive bronchopneumonia. This ought not to 
develop, if he has proper care and treatment. 

Treatment. The treatment of bronchitis depends on the 
stage of the bronchitis and the condition of the bronchial 
mucous membrane. The bronchitis in this instance has 
passed the early stage. The bronchial mucous membrane 
is still somewhat swollen and reddened, but is no longer dry. 
It is relaxed and is secreting moderately freely. It is time, 
therefore, to stop the ipecac, which is a sedative expectorant, 
and give one of the so-called "stimulant" expectorants to aid 
the mucous membrane to clear itself of the products of 
inflammation within it and to restore its tone. The best of 
them is the chloride of ammonium. One-half of a grain every 
two hours will be enough for him. The taste is best dis- 



352 CASE HISTORIES IN PEDIATRICS. 

guised by the fluid extract of licorice. The following pre- 
scription is a suitable one : 

Chloride of ammonium gr. xii 

Fluid extract of licorice 3 ii 

Water ad 5 iv 

Sig. One teaspoonful every 3 hours. 

The chloride of ammonium is given for its action on the bron- 
chial mucous membrane, not directly for the symptom, cough, 
and should, therefore, be given continuously. If his cough is 
very troublesome, he may be given five or ten drops of pare- 
goric, in water, every two or three hours to control it. The 
paregoric should not be given any oftener than is necessary, 
however, because, if it is given too freely, it will prevent him 
from clearing his tubes thoroughly and will thus do harm. 
It will be well to continue the vaporization of the compound 
tincture of benzoin, although it is usually less effective in this 
than in the early stage. 

He should have plenty of fresh air, but will probably be 
more comfortable if the room does not go below 60° F. He 
should stay in bed. His diet should consist of milk, junket, 
cereals, milk toast, bread, broth and custard. 



DISEASES OF THE BRONCHI, LUNGS AND PLEURAE. 353 

CASE 106. Mary J., nine months old, had always been a 
well, strong baby. She began to have a little running from 
the nose March i. March 3 she began to cough a good deal 
and to have a little fever. March 4 she had more fever, 
coughed a great deal and had considerable rattling in the 
chest. She took but little food, but digested that little well. 
She grew rapidly worse and was seen in consultation the 
night of March 5. 

Physical Examination, She was well developed and nour- 
ished, but markedly cyanotic. The alse nasi moved with 
respiration. She was unable to lie down and was very rest- 
less. The examination was superficial because of her critical 
condition. The throat showed nothing abnormal. The 
cardiac area was not determined ; the action was regular, the 
sounds feeble. There was sinking in of the supraclavicular 
and lower intercostal spaces, as well as of the epigastrium, 
with each inspiration. There was vesicular resonance all 
over the lungs. The respiratory sound was feeble, but normal 
in character. The vocal resonance was not determined. 
Both chests were full of fine and medium moist rales, the fine 
predominating. The rales were easily palpable. The ex- 
tremities were cold and the whole body covered with perspira- 
tion. The temperature was not taken. The pulse was faster 
than could be counted. The respiration was 80. 

Diagnosis. The diagnosis is, without question. Bronchitis. 
The finer and medium-sized tubes are involved to a much 
greater degree than the larger. 

Prognosis. The condition is a very critical one and, while 
not hopeless, the chances are very much against recovery. 
She will probably not live twenty-four hours. If she does, 
her chances are somewhat better. 

Treatment. Her condition is critical and the treatment 
must be immediate and energetic. The first indication is to 
clear out the bronchial tubes. Alternate dippings in water 
from 105° F. to 110° F. and from 65° F. to "j^" F., as is done 
in resuscitating new-born infants, will probably make her cry, 
breathe deeply and cough, and in this way get rid of the 
excessive secretion. If this method is not successful, the wine 
or syrup of ipecac, in teaspoonful doses, will make her vomit 



354 ^ASE HISTORIES IN PEDIATRICS, 

and in this way clear out the bronchial tubes. She must then 
be given plenty of fresh air and, if necessary, oxygen. The 
oxygen is given for the symptom, cyanosis, and must be given 
continuously as long as the cyanosis lasts, not intermittently 
as it usually is. The dippings and ipecac may be repeated as 
necessary. It must not be forgotten, however, that ipecac 
used in this way is depressing and, consequently, a dangerous 
remedy. If the dippings and ipecac do not relieve her, atropin, 
in doses of 1-500 grain, may be given subcutaneously with the 
object of diminishing the secretion. 

She also needs immediate stimulation. Strychnia is a 
respiratory as well as a cardiac stimulant and is, therefore, 
doubly indicated. It should be given subcutaneously, in 
doses of 1-300 grain, every two or three hours, as necessary. 
Caffeine-sodium benzoate, or salicylate, in doses of from 
one eighth to one fourth of a grain, given subcutaneously, 
will also aid in keeping up the heart. 

She should be fed every two hours, and will probably not 
take more than an ounce at a time, if she does that. She will 
probably not be able to take the bottle. The best way to 
give the food is with a Breck feeder. If she will not take it 
in this way, a dropper or spoon may be tried. Human milk 
is the best food for her ; next to this, a weak modified milk, 
for example, one containing 2% of fat, 6% of sugar, 0.75% of 
whey proteids and 0.25% of casein. 



DISEASES OF THE BRONCHI, LUNGS AND PLEURA. 355 

CASE 107. Clifton R., two years old, had always been 
well. Four days before he was seen, while eating dried figs 
in a room with his brother who was playing with some nails, 
he suddenly began to cough and choke. His mother picked 
him up by the heels and slapped his back and he vomited his 
last meal together with a quantity of figs. He continued to 
cough almost constantly and at times had attacks of choking. 
He coughed up what was thought to be a piece of fig early the 
next morning during one of these attacks. There was, how- 
ever, no improvement in the symptoms after it. The tem- 
perature went up to 102° F. on the third day and at his 
entrance to the Children's Hospital the next day was 103"^ F. 
He had eaten very little for two days, but had had no diffi- 
culty in swallowing and had shown no symptoms of indiges- 
tion. 

Physical Examination. He was well developed and nour- 
ished, but a little pale. He was clear mentally. There was 
no nasal discharge and he kept his mouth shut. The throat 
showed nothing abnormal to either inspection or palpation. 
The ear-drums were normal. He was short of breath, but 
was able to lie down. His voice was clear. There was no 
dullness under the manubrium and the thymus was not 
palpable above it. There was no increased dullness in the 
middle back and the bronchial voice sound was not heard 
below the seventh cervical spine. The heart was normal, 
except that the second pulmonic sound was slightly accentu- 
ated. The chest was symmetrical, but the left side moved 
less in respiration than the right. The respiratory sound 
was much diminished over the whole left chest, but normal in 
character. The voice sounds and fremitus were slightly dimin- 
ished on the left side and an occasional dry rale was heard on 
that side, both in front and behind. There was no change in 
the percussion note. The lower border of the liver was palpa- 
ble two cm. below the costal border in the nipple line. The 
spleen was not palpable. The abdomen, genitals and extrem- 
ities were normal, as were the deep reflexes. The rectal tem- 
perature was 103° F. ; the pulse, 136; the respiration, 40. 

The urine was pale, acid in reaction and contained no 
albumin or sugar. The sediment showed a few leucocytes, 
small round and squamous cells. 



356 CASE HISTORIES IN PEDIATRICS. 

A Roentgenograph showed no foreign body in either the 
trachea or bronchi. 

Diagnosis. The physical examination shows nothing in 
the nose, nasopharynx, throat or larynx to account for the 
symptoms, and there are no signs of enlargement of the thy- 
mus or bronchial lymph nodes which might cause pressure on 
the trachea or bronchi from without. The physical signs are 
inconsistent with solidification of the lung or an accumula- 
tion of fluid. The rales do not show a sufficient amount of 
bronchitis to account for the severity of the symptoms. The 
sudden onset of the coughing and choking points very strongly 
to the inhalation of some foreign body, in this instance either 
a piece of fig or a nail. The normal condition of the throat 
and the clear cry prove that it cannot be located above the 
trachea. The fact that less air enters the left chest than the 
right and that the respiratory sound is diminished equally 
over the whole left side show that the Foreign Body must 
have passed through the trachea and lodged in the Left 
Primary Bronchus. The absence of a shadow in the 
Roentgenograph shows that it cannot be a nail. It must, 
therefore, be a piece of fig, which would not give a shadow. 
The rise in temperature indicates that there has been an 
infection of the bronchus; the rales, a secondary bronchitis 
or an accummulation of the bronchial secretions from in- 
ability to clear the tubes properly. 

Prognosis. The prognosis is very grave unless the piece 
of fig can be removed very soon. It may soften and be 
coughed up before much damage has been done to the bron- 
chus. The fever shows, however, that considerable harm has 
already been done. The chances are, therefore, that before 
it is expelled an abscess or gangrene of the lung will have 
developed which will eventually cause death. 

Treatment. Bronchoscopy should be done at once by a 
thoroughly competent man, and, if the piece of fig can be seen 
and grasped, it must be removed. If it cannot be removed, 
there is little to do at present except to look after the gen- 
eral condition. If evidences of abscess or gangrene of the 
lung develop, an attempt should be made to reach it from the 
outside. Even if the operation is successful, he will, however, 
probably not recover. 



DISEASES OF THE BRONCHI, LUNGS AND PLEUR.E. 357 

CASE 1 08. Benjamin A. was seen in August, 1909, when 
seven years old. His father was rheumatic; his mother and 
four other children were well. He had had measles and 
whooping-cough when two years old and chicken-pox at six 
years. He had had an operation for the removal of adenoids 
in 1906 and another in 1908. One tonsil was also supposed 
to have been removed at the latter operation. In April, 1907, 
when at his home in Mt. Vernon, Ohio, he had a very severe 
attack of asthma, lasting several weeks. He had another 
severe attack in July, 1907, while visiting at Port Huron. He 
then went to the island of Mackinac, where he was immedi- 
ately relieved. He spent the summer there and had only one 
slight attack. During the winter of 1907-08, which was 
spent in Mt. Vernon, he had many slight attacks, which 
continued during the spring of 1908, when he was in Jackson- 
ville, 111. He passed the summer in the Rocky Mountains at 
an altitude of 6000 feet and was perfectly well. He slept out 
of doors at home during the winter of 1908-09 and had only 
a few mild attacks. About a week before he was seen, while 
at Bass Rocks, Mass., he had the most severe attack since the 
first one. He had been fairly well between the attacks, but 
always kept his mouth open and snored at night. He was 
rather indiscreetly fed and was subject to mild attacks of 
indigestion. His mother thought that some of the attacks 
of asthma were brought on by indigestion and that she had 
been able to abort some of them by giving calomel at the 
beginning. She had not been able to trace any connection 
between the attacks and any special article of food. 

Physical Examination. He was well developed and nour- 
ished and of good color. He kept his mouth open and had a 
typical adenoid face. A considerable amount of soft ade- 
noids was felt with the finger. The tonsils were much en- 
larged and did not look as if they had ever been touched. 
The tongue was nearly clean; the teeth were good. The 
area of cardiac dullness was normal, while the area of flatness 
was much diminished. The heart sounds were normal. The 
respiration was somewhat wheezy and expiration was pro- 
longed. The^^chest was everywhere hyperresonant. The 
respiratory sound was normal in character, but the expiration 



358 CASE HISTORIES IN PEDIATRICS. 

was prolonged. There was no change in the vocal resonance 
or fremitus. A moderate number of sibilant rales was heard 
on both sides, both behind and in front. The upper border 
of the liver flatness was at the upper border of the eighth rib 
in the nipple line; the lower border was not palpable. The 
spleen was not palpable. The abdomen showed nothing 
abnormal. The extremities were normal. There was no 
spasm or paralysis. The knee-jerks were equal and normal. 
There was no enlargement of the peripheral lymph nodes. 

Diagnosis. The wheezy respiration, prolonged expiration 
and sibilant rales confirm the diagnosis of Asthma, which was 
made by his former physicians. The hyperresonance of the 
chest, the diminution of the area of cardiac flatness and the 
displacement of the lung-liver boundary downward show that 
there is a moderate degree of Emphysema of the Lungs. He 
also has Adenoids and Chronic Hypertrophy of the 
Tonsils. 

Prognosis. The prognosis in this, as in all cases of asthma, 
is indefinite. There is no way of finding out whether he will 
continue to have attacks all his life or whether they will sooner 
or later cease. The chances of recovery are, however, better 
than they would be if he was an adult. The outlook is more 
favorable than usual in this instance, moreover, because there 
is an abnormal condition in the throat which may be at the 
bottom of the trouble. If this is so, the removal of the tonsils 
and adenoids will probably stop the attacks. If the asthmatic 
attacks cease, the emphysema will diminish and what remains 
will be corrected through the changes incident to the growth 
of the lungs. 

Treatment. The adenoids and tonsils should be removed 
at once. He should then be taken to a high and dry climate, 
where experience has shown that he does best. It will be 
wiser for him to remain away from home for a year but, if 
this is not feasible, he should sleep out of doors as he did last 
winter. There are no definite indications as to diet, as he has 
little or no disturbance of the digestion and no connection 
between the attacks and any special articles of food has been 
made out. He should be given a reasonable, simple diet for 
his age. In spite of the facts that he shows no evidences of 



DISEASES OF THE BRONCHI, LUNGS AND PLEURiE. 359 

disturbance of the digestion and that no connection has been 
made out between the attacks and any special articles of 
food, it is possible that they may be manifestations of ana- 
phylaxis as the result of a sensitization to the proteins of 
some food or foods. If the attacks persist after the removal 
of the tonsils it will be wise, therefore, to try the skin test 
for sensitization to as many of the pure food proteins as 
possible. If he shows sensitization to any food, it should 
be cut out of his diet. The attempt may be made later to 
immunize him to it. If he is not found to be sensitized to 
any foods or the attacks persist when the food to which he 
is sensitive is eliminated from his diet, it will be well to try 
the effect of iodide of potassium, given over considerable 
periods of time, in doses of from three grains to five grains, 
three times daily, after meals. It is best administered in 
essence of pepsin. The syrup of hydriodic acid may be used 
if desired. The objection to it, however, is that, as a tea- 
spoonful represents only a little more than one grain of the 
iodide of potassium, the quantity of syrup which has to be 
given in order to give enough of the iodide is liable to disturb 
the digestion. 

He will probably be most comfortable during an attack in 
a room at from 66° F. to 6S^ F., with the air somewhat moist. 
Nitrate of potassium paper or some of the various asthma 
powders should be burned in the room. These powders are 
all more or less similar in their composition, being, as a rule, 
made up of various combinations of nitrate of potassium, 
belladonna, hyoscyamus and stramonium leaves and opium, 
yet one combination is most effectual in one case and another 
in another. It will be well, therefore, to try different com- 
binations until one is found which relieves him. It will also 
be advisable to try the subcutaneous injection of from three 
to five minims of the i-iooo solution of adrenalin chloride, 
which in some instances is very efficacious. If these measures 
do not relieve him, it may be necessary to give him a few 
whiffs of chloroform or a subcutaneous injection of morphia. 
It will be wise to give him one thirty-second of a grain first; 
if this does not relieve him, the dose may be increased to one- 
sixteenth or even to one-eighth of a grain. 



360 CASE HISTORIES IN PEDIATRICS. 

CASE 109. George B., six years old, was the youngest 
child of healthy, but markedly neurotic, parents. He was 
very nervous and excitable as an infant and unusually pre- 
cocious in his mental development. He began to have 
eczema at six months which lasted until he was eighteen 
months old, although he was entirely breast-fed when it 
first appeared. He had whooping-cough mildly when two 
two years old and a severe attack of bronchopneumonia 
about a year later. He began to be wheezy soon after the 
attack of bronchopneumonia, the wheeziness persisting for 
a number of months. At times it was hardly noticeable, 
at others it was quite severe. His adenoids and tonsils were 
removed after six months. The wheeziness then almost 
ceased, and he was very well until he was five years old. 
Since then he had always been more or less wheezy and 
recently had been worse than ever before. At times his 
breathing was so difiicult that he was unable to lie down. 

The season of the year made no difference in his symptoms. 
They were worse on windy days, however, especially if the 
wind was from the east. Dust apparently had no effect, 
because he was more comfortable when riding in an auto 
or a carriage than when in the house. He lived on a farm 
and was no worse when he was in the barn with the animals 
than when he was out of doors. His mother had noticed 
no connection between his difficulty in breathing and any 
article of food. 

Physical Examination. He was tall and slim. His color 
was good. His respiration was wheezy and expiration was 
prolonged. He had no tonsils and there was nothing ab- 
normal about his throat or nose. His shoulders were a little 
high and his sternum somewhat elevated. His thorax was 
more rounded than normal. The whole chest was somewhat 
hyperresonant. The respiration was vesicular in character, 
but expiration was prolonged. There was no change in the 
vocal resonance or tactile fremitus. A few sibilant rales 
were heard over both lungs, both in front and behind. There 
was no retraction of the intercostal spaces or epigastrium 
with inspiration. The deep cardiac area was normal; the 
superficial area could not be determined because of the 



DISEASES OF THE BRONCHI, LUNGS AND PLEURAE. 361 

hyperresonance of the chest. The sounds of the heart were 
normal. The lower border of the lung on the right was in 
the sixth space in the nipple line. D'Espine's sign was 
absent. There was no dullness under the manubrium and 
the thymus was not palpable in the suprasternal notch. 
The rest of the physical examination showed nothing ab- 
normal. 

Diagnosis. The physical examination shows that the dif- 
ficulty in breathing is not due to obstruction anywhere in 
the respiratory tract above the large bronchi. The shape of 
the chest, the hyperresonance, the diminished superficial 
cardiac area, the downward displacement of the lung border 
and the prolonged expiration are characteristic of Emphy- 
sema OF the Lungs. The rales show that he has Bron- 
chitis. The history of his illness taken in connection with 
the character of the rales and the evidences of emphysema 
prove that he also has Asthma. 

Prognosis. The prognosis in this, as in all cases of asthma, 
depends largely on whether the cause or causes of the asthma 
can be discovered. If they can, the disease can probably 
be cured. If they can not, the chances of ultimate recovery 
are better in childhood than in later life. 

Treatment. The fact that his nose and throat are normal 
shows that the asthma is not due to disease of these organs 
and makes it improbable that it is due to sensitization to 
bacterial proteins. The fact that being with animals does 
not exaggerate his symptoms makes it improbable that they 
are due to sensitization to animal emanations, while the fact 
that he has the asthma at all seasons practically excludes the 
pollens of plants as the etiological factor. The fact that no 
connection has been noticed between the ingestion of any 
article of food and his attacks does not exclude anaphylaxis 
to food proteins as the cause of his symptoms, but makes it 
somewhat unlikely. It is not safe to assume, however, that 
his symptoms may not be due to sensitization of some sort, 
without testing him out to pollens, food proteins and ani- 
mals, as sensitization is not infrequently present, although 
not suggested by the history. 

He was tested out in this way and it was found that he 



362 CASE HISTORIES IN PEDIATRICS. 

was sensitive to milk and the keratin extract of horses' 
hair and cats' hair, but insensitive to other foods, pollens 
and the serum of both horses and cats. It was obvious that 
in spite of his reaction to the hair of horses this could not be 
the cause of his symptoms, because there was no clinical 
connection between them and association with horses. It 
was also obvious that the best way to find out whether 
either or both milk and the emanations of the cat were the 
cause of his symptoms was to cut all milk out of his diet and 
to keep him away from cats. If his symptoms were not 
relieved it would be evident that they were not the cause. 
If they were relieved, it would be necessary to give him milk 
and keep him away from cats at one time, and at another to 
give him no milk and aUow him to play with cats, in order to 
determine whether it was only milk or only cats, or both, 
which were the cause of the symptoms. These things were 
done, and it was found that he was free from the trouble 
when he had no milk and was kept away from cats, but was 
asthmatic when he had milk to drink and did not play with 
cats or played with cats and had no milk to drink. It was 
also found that the small amount of milk used in cooking 
had no bad effect. 

The treatment for him, therefore, is to keep him away 
from cats entirely and to give him no milk to drink. It will 
also be well to attempt to immunize him to milk by giving 
him very small amounts at first and gradually increasing 
them* 



DISEASES OF THE BRONCHI, LUNGS AND PLEUILE. 363 

CASE 1 10. Lizzie O., four years old, began to cough early 
in April. She began to whoop in about a week. She was but 
little depressed by the whooping-cough and got on very well 
until about the first of May. The cough then became worse, 
she lost her appetite and failed in flesh and strength. She 
began to be feverish and on May 6 went to bed. From that 
time she grew rapidly worse. She had frequent paroxysms of 
whooping and much cough without whooping. She raised a 
good deal of mucopurulent sputum. She was unable to lie 
down with comfort the night of May 8 and was more or less 
blue. She took almost no nourishment and was very restless. 
She was seen in consultation May 9. 

Physical Examination. She was fairly developed and nour- 
ished but had evidently lost considerable weight. She was 
bolstered up by pillows in a reclining position as she was 
unable to lie flat. There was marked cyanosis of the face and 
extremities. The alse nasi moved with respiration. She ap- 
peared very sick. Examination of the throat showed nothing 
abnormal. There was no retraction of the supraclavicular or 
intercostal spaces, but a little of the epigastrium. The 
cardiac impulse was diffuse; the apex in the fifth space just 
outside the nipple line. The upper border of relative dullness 
was at the lower border of the second rib; the right border 
nearly at the right parasternal line. The first sound was 
short and rather feeble, and at the mitral area was followed by 
a soft blowing murmur. The second pulmonic sound was no 
louder than the second aortic. There was dullness on per- 
cussion in the lower left back below the angle of the scapula, 
and extending outward from the spinous processes to the 
scapular line. In this area the respiration was bronchial in 
character, but diminished in intensity. The vocal resonance 
and fremitus were increased. There were numerous high- 
pitched, fine and medium moist r^les. In the right axilla, 
at about the level of the sixth rib, there was an area of dullness 
about the size of a silver dollar. Respiration was here broncho- 
vesicular and accompanied by many fine, moist, high-pitched 
rales. Elsewhere respiration was normal in character, but 
diminished in quantity. There were many medium and 
coarse moist rales throughout both chests. The abdomen 



364 CASE HISTORIES IN PED^ATRICS. 

showed nothing abnormal. The liver and spleen were not 
palpable. The extremities were normal. The knee-jerks 
were equal and normal. There was no edema and no enlarge- 
ment of the peripheral lymph nodes. The rectal temperature 
was 104° F., the pulse 200, and the respiration 88. 

Diagnosis. The signs of bronchitis and the presence of 
two separate areas of solidification in the lungs prove that 
she has a Bronchopneumonia. There is nothing about the 
physical signs to show whether this is or is not tubercular. 
While it is true that whooping cough, more than any other 
disease except m^easles, predisposes to the development of 
tuberculosis, the infection far more often takes the form of 
a bronchial adenitis than of a bronchopneumonia. Non- 
tubercular bronchopneumonia is very common in whooping 
cough; tubercular, very rare. The chances are, therefore, 
very much in favor of its being non-tubercular. The finding 
of tubercle bacilli in the sputum would, of course, prove 
it to be tubercular; their absence would not exclude tubercu- 
losis. The process is so acute that the skin tuberculin test 
would probably be negative even if it is tubercular. The 
white blood count would not help because, even if the broncho- 
pneumonia is primarily tubercular, there is almost certainly a 
secondary infection which will cause a leucocytosis. It is of 
no importance anyway, in her present condition, to make a 
diagnosis between the two forms, because it will make no 
difference in the treatment. 

The diffuse cardiac impulse, the enlargement of the heart 
upward and to the right, the short, feeble first sound, and the 
diminution of the second pulmonic sound (the second pul- 
monic sound is normally louder than the second aortic at 
this age) show marked weakness and dilatation. The systolic 
murmur at the apex is almost certainly due to a relative in- 
sufficiency of the mitral valve, as there is no reason to suspect 
an endocarditis, and the dilatation of the heart is amply suffi- 
cient to account for an insufficiency. It is impossible to deter- 
mine whether the dilatation of the heart is due to the strain 
of coughing, to a myocarditis in connection with the broncho- 
pneumonia, or to both. The chances are that it is largely 
due to the strain of coughing, which falls on the right side of 



DISEASES OF THE BRONCHI, LUNGS AND PLEURA. 365 

the heart, since only the right side of the heart is enlarged, 
while the enlargement is usually more uniform in myocarditis. 
It is very probable, however, that there may be a small 
myocarditic element. 

Prognosis. She is in a very serious condition. She has 
hardly reached the height of her whooping-cough, she has 
bronchopneumonia and her heart is dilated. She has a chance 
of recovery, but only a small one. 

Treatment. The first thing to do is to favor oxygenation 
of the blood by giving her a liberal supply of fresh air. At 
this time of year she may be put out of doors or by the open 
window. If fresh air does not relieve the cyanosis, she must 
be given oxygen. The indication for oxygen is cyanosis. She 
should, therefore, be given oxygen continuously as long as she 
is cyanotic, not intermittently, as is usually done. 

The next indication is to stimulate the heart. Her con- 
dition demands a quick stimulant at once. Sulphate of 
strychnia in doses of 1-120 grain, or caffeine-sodium benzoate 
or salicylate, in doses of one half a grain, repeated every two 
hours to every four hours, as necessary, are the best drugs. 
Aromatic spirits of ammonia, in fifteen-drop doses, may tide 
over an emergency. She also needs a cardiac tonic to 
strengthen and build up the heart wall. Digitalis is the best 
of the cardiac tonics. Five drops of the tincture every four 
hours will be none too much for her at present. If the digitalis 
takes hold, the strychnia and caffein may be diminished or 
omitted. She should be fed every two hours with small 
amounts of milk and soft solids, such as custard, junket, 
smooth cereals, blanc mange and ice cream. 

The results of the treatment of whooping-cough are at 
best most unsatisfactory. To do good, the drugs must be 
given up to their physiological limit. In such doses they will 
certainly do harm in this instance. If the lungs are not too 
much filled up, there is no objection to giving morphia, in 
doses of from one thirty-second to one twenty-fourth of a 
grain, to control excessive cough, nervousness, sleeplessness 
and discomfort. It may be worth while to try vaccines of the 
Bordet-Gengou bacillus. She will, however, probably be 
dead or much better before they can have much effect. 



366 CASE HISTORIES IN PEDIATRICS. 

CASE III. William R., twenty- three months old, was 
the third child of healthy parents. The other children were 
well. There had been no deaths or miscarriages. He had 
had no known exposure to tuberculosis. He was not nursed, 
but had been artificially fed from the first by his mother 
without professional advice. He had a severe attack of 
diarrhea, lasting a month, when six months old. Since then 
he had been pale and delicate and had had frequent attacks 
of indigestion. 

He broke out with measles, March i8. The attack was a 
light one and he seemed all right, March 23. Two days 
later, however, he began to cough and seemed feverish. He 
was seen by his physician March 2*], His rectal temperature 
was then 102° F., his pulse 150 and his respiration 50. There 
were many moist rales in both sides of the chest, but no signs 
of solidification. The temperature was higher the next day, 
but he gradually improved up to the morning of April i, the 
temperature having dropped to 102° F., the pulse to 130 and 
the respiration to 40, while the cough had diminished. 
Since then his temperature had ranged between 103° F. and 
104° F. and his respiration had become more rapid, while 
expiration was accompanied by a moan. He had taken his 
food reasonably well, had not vomited and had had normal 
movements from the bowels, but had, nevertheless, failed 
considerably in general condition. He had been quiet, except 
when coughing, and had slept the greater part of the time. 
His mother had refused to open the windows or to force him 
to eat. He was seen in consultation at 11 a.m., April 2. He 
was found in a small room with double windows, the windows 
and doors being shut tight and the shades pulled down. 

Physical Examination. He was small and poorly nourished. 
He was markedly pale, but not at all cyanotic. He was 
feeble, but conscious. He had sixteen teeth. There was no 
nasal discharge and the throat was normal. The tongue was 
moderately dry and considerably coated. The cardiac im- 
pulse was neither visible nor palpable. The left border of the 
cardiac dullness was six cm. to the left of the median line, 
the upper border at the lower border of the second rib, and 
the right border two cm. to the right of the median line. The 



DISEASES OF THE BRONCHI, LUNGS AND PLEUR.E. 367 

first sound was of fair strength. The second sound at the 
pulmonic area was moderately accentuated. There were no 
murmurs. A few medium and coarse, moist r^les were heard 
over the left lung, both in front and behind. There was 
moderate dullness with diminished respiration over the right 
lower lobe. The respiration was normal in character, except 
in a small spot in the axilla, where it was broncho-vesicular. 
The voice sounds and tactile fremitus were not changed. 
Very many fine, moist riles were heard over the whole right 
lower lobe, and a moderate number of fine and medium, moist 
relies over the upper and middle lobes. The abdomen was 
normal. The lower border of the liver was just palpable in 
the nipple line. The spleen was not palpable. The extremi- 
ties were normal. There was no spasm or paralysis. The 
knee-jerks were equal, but diminished. There was no en- 
largement of the peripheral lymph nodes. His rectal tem- 
perature was 104° F.; his pulse, 160; his respiration, 72. 

Diagnosis. The riles show that there is a general Bron- 
chitis. The dullness, diminished respiration and fine, moist 
riles over the right lower lobe show that there is an exudation 
into the alveoli and beginning solidification. The broncho- 
vesicular respiration in the axilla shows that the process has 
in this spot gone on to complete, or nearly complete, solidifi- 
cation, that is, that there is also a Bronchopneumonia. 
The accentuation of the second pulmonic sound is due to the 
increased pressure in the pulmonary circulation resulting 
from the obstruction to the flow of blood through the lungs. 
The process in the lungs may be either tubercular or non- 
tubercular. The physical signs are equally consistent with 
either condition. The absence of any known exposure to 
tuberculosis does not count especially against a tubercular 
bronchopneumonia, because every baby is exposed to tuber- 
cular infection many times before it is two years old. Measles 
is, moreover, more likely than any other disease, except 
whooping-cough, to light up a latent tubercular focus. Simple 
bronchopneumonia is, however, very common, while tuber- 
cular bronchopneumonia is relatively rare. The chances are, 
therefore, that he has a non-tubercular bronchopneumonia. 
The sputum can probably be obtained without much difficulty 



368 CASE HISTORIES IN PEDIATRICS. 

by introducing a cotton swab into the pharynx and making 
him cough. The finding of tubercle bacilli in the sputum will 
make the diagnosis of tuberculosis positive. Tuberculosis 
cannot be excluded, however, if they are not found. A skin 
tuberculin test may also be tried. If it is negative, tuber- 
culosis can be practically excluded ; if it is positive, a probable 
diagnosis of tubercular bronchopneumonia is justified. 

Prognosis. He is seriously ill. The facts that he has 
always been delicate and has never had a good digestion are 
against him. On the other hand, however, there are no 
evidences of cardiac weakness, there are no signs of solidifica- 
tion except in the right lower lobe, his digestion is now good, 
he is willing to take food and he is clear mentally. He has, 
moreover, not had any fresh air or proper nursing. It is 
reasonable to expect that he will do better when these are 
provided, as they must be. The chances are, therefore, 
considerably in his favor. 

Treatment. The first and most important thing in the 
treatment is^to move him into a room without double win- 
dows, push up the shades, open the windows and give him 
a large amount of fresh air and sunlight. The next thing to 
do is to get a capable nurse to keep the windows open and 
the shades up, and to make him take his food. He should 
be fed every three hours with milk and starchy foods. He 
may also have orange juice, if he likes it. His temperature 
is not very high, is not causing any disturbance of the nervous 
system, and, therefore, requires no treatment. There are no 
evidences of cardiac weakness. Stimulants are consequently 
not needed. The fresh air will almost certainly relieve his 
cough. There are no drugs which will help the broncho- 
pneumonic process in the lung. The bronchitis is not very 
severe and he is clearing his tubes well. There is, therefore, 
no urgent need of expectorants, which are, moreover, more 
likely to disturb his digestion than to alleviate the patho- 
logical condition in the bronchi. It will be wiser, therefore, 
not to give them to him. 



DISEASES OF THE BRONCHI, LUNGS AND PLEUR/E. 369 

CASE 112. Andrew D., seven months old, was the third 
child of healthy parents. The other children were well and 
there had been no miscarriages. There was no tuberculosis in 
either family and there had been no known exposure to it. He 
was born at full term, after a normal labor, was normal at birth 
and weighed seven and one-quarter pounds. He had always 
been well, except for a very mild attack of whooping cough, 
from which he had recovered, a month before. He was 
nursed for several months and did very well. Since then he 
had been given a mixture of three parts of whole milk and 
one part of water, to which Mellin's Food had been added. 
He had thrived on that as well as he had on the breast-milk. 

He had a convulsion, followed by fever, the morning of 
April II. His temperature had been about 103° F. since 
then and he had had four more convulsions, the last one 
during the evening of the eleventh. He was given castor oil 
immediately after the first convulsion and had had several 
loose, green, curdy stools as the result. He had not vomited, 
coughed, or shown any evidences of pain. He was seen in 
consultation at 5 p.m., April 12. 

Physical Examination. He was fairly developed and 
nourished, and of fair color. He was clear mentally. The 
anterior fontanelle was three cm. in diameter and level. 
There was no rigidity of the neck or neck-sign. The pupils 
were equal and reacted to light. The ear drums were normal. 
There was no nasal discharge, but the pharynx was slightly 
reddened. The cardiac impulse was indistinctly palpable six 
cm. to the left of the median line. The left border of the car- 
diac dullness corresponded to the impulse. The right border 
was two cm. to the right of the median line; the upper 
border was in the third space. The action was regular and 
the sounds normal. The second pulmonic sound was slightly 
accentuated. The respiration was rapid and grunting and 
the alae nasi moved. The left chest did not move quite as 
much as the right and the respiratory sound was not quite 
as loud in the left back as elsewhere. Nothing else abnormal 
was detected in the lungs. The level of the abdomen was 
that of the thorax. It was everywhere tympanitic and there 
was no tenderness or spasm. The lower border of the liver 



370 CASE HISTORIES IN PEDIATRICS. 

was palpable one cm. below the costal border in the nipple 
line. The spleen was not palpable. The extremities were 
normal. There was no spasm or paralysis. The knee-jerks 
were equal and normal. Kernig's sign was absent. There 
was no enlargement of the peripheral lymph nodes and no 
eruption. The rectal temperature was 103° F.; the pulse, 
140; the respiration, 72. 

Diagnosis. The sudden onset, the continued high fever 
and the relative increase in the rate of the respiration over 
that of the pulse (i to 2 instead of the normal i to 4) are 
sufficient, in the absence of all physical signs of other diseases, 
to justify an almost positive diagnosis of Pneumonia. The 
diminution of the motility and of the respiratory sound on the 
left side, which are not infrequently the earliest physical 
signs of pneumonia, are sufficient to make this diagnosis 
certain. The grunting respiration and the motion of the 
alae nasi are corroborative evidence. The absence of cough 
does not count materially against pneumonia, because cough 
is often absent in the early days of pneumonia in infancy. 
Meningitis, which is suggested to a certain extent by the 
continuance of the convulsions, can be excluded on the level 
fontanelle and the absence of all physical signs of cerebral 
irritation. The loose, green stools are undoubtedly due to 
the castor oil, together with some disturbance of the digestion 
from the fever. 

Prognosis. He is not at present dangerously ill. This 
is only the second day of the disease, however, and he would 
naturally not show much constitutional depression at this 
time. It is too early, therefore, to give any definite prognosis. 
Pneumonia is, however, a very serious disease in infancy, very 
different from what it is in childhood. The prognosis should, 
therefore, be guarded. All that can be said is that he is doing 
well now and that it is impossible to say whether he will 
recover or not. 

Treatment. See Cases 113 and 114. His temperature is 
not unduly high and he has shown no evidences of disturbance 
of the nervous system for nearly twenty-four hours. The 
fever, may, therefore, be disregarded. There is no dis- 
turbance of the heart or circulation. Stimulation is, there- 



DISEASES OF THE BRONCHI, LUNGS AND PLEURA. 371 

fore, contraindicated. He has been doing well on his present 
food. It will not be well to change it now that he is sick, 
although it is not an ideal one. It will be advisable, however, 
to dilute it one-half with water. He should be given eight 
feedings of four ounces, at intervals of three hours. He should 
also be given water freely. 



372 CASE HISTORIES IN PEDIATRICS. 

CASE 113. Michael D., seven years old, went to school on 
the morning of January 24 perfectly well, as far as was known, 
except that his bowels had not moved for nearly a week. 
While playing at recess one of his playmates struck him in 
the abdomen with his fist. Shortly afterward he became 
faint and nauseated and was sent home by his teacher. He 
vomited soon after reaching home and continued to do so for 
twenty-four hours. He was given two grains of calomel in 
divided doses during the afternoon and night of the 25th, 
and a teaspoonful of Epsom salts the next morning, but his 
bowels had not moved. He continued to complain of nausea, 
headache and pain in the abdomen. The abdominal pain was 
general, not localized. He had coughed a little since the morn- 
ing of the 26th. He had felt very hot, but his temperature had 
not been taken. He had not been delirious. He was seen 
about 4 P.M., January 26. 

Physical Examination. He was fairly developed and nour- 
ished. He was perfectly clear mentally. The cheeks were 
flushed. His face was not pinched. The alae nasi moved with 
respiration. The tongue was moist and moderately coated. 
The throat was slightly reddened, but w^as otherwise normal. 
The cardiac impulse was in the fifth space, just inside the nip- 
ple line. The right border of dullness was i cm. to the right of 
the right sternal border, the upper border at the middle of the 
third rib. The sounds were normal. The second pulmonic 
sound was somewhat the louder. There was slight dullness 
in the right back below the angle of the scapula with slightly 
diminished respiration of normal character. The vocal reso- 
nance and fremitus were normal. There were no rales. The 
upper border of the liver flatness was at the upper border of 
the sixth rib, the lower border was not palpable. The spleen 
was not palpable. The level of the abdomen was considerably 
above that of the thorax; it was everywhere tympanitic. 
There was no muscular spasm, but the whole abdomen was 
somewhat tender, the tenderness being most marked in the 
right iliac fossa. There was, however, no tumor or dullness 
in this region. There were no evidences of free fluid in the 
abdomen. The extremities were normal. There was no 
spasm or paralysis; the knee-jerks were equal and diminished; 



DISEASES OF THE BRONCHI, LUNGS AND PLEURAE. 373 

there was no Kernig's sign. There was no enlargement of 
the peripheral lymph nodes. Rectal examination showed 
nothing abnormal beyond a mass of hard feces in the rectum. 
The rectal temperature was 104° F., the pulse 140, the respira- 
tion 60. 

The urine was high in color, extremely acid in reaction, 
and of a specific gravity of 1,030. It contained no albumin or 
sugar, but a large excess of urates. The sediment showed 
nothing abnormal. 

The leucocyte count was 36,000. 

Diagnosis. The history of the acute onset of vomiting 
and pain in the abdomen immediately after a blow in that 
region makes some acute inflammatory condition in the ab- 
domen seem the most obvious diagnosis. The persistent 
constipation, the continuance of the pain and the abdominal 
distention and tenderness all corroborate this diagnosis. 
The greater tenderness in the right iliac fossa points to an 
involvement of the appendix. Further consideration, how- 
ever, makes this diagnosis seem less probable. The absence of 
the pinched face, of free fluid in the abdomen and of muscular 
spasm makes general peritonitis very improbable. The 
absence of localized spasm, tumor and dullness in the right 
iliac fossa and the negative results of the rectal examination 
practically rule out appendicitis. The blow of another small 
boy could hardly rupture any organ, there was no collapse 
and there are no signs of peritonitis, as would be expected if 
any organ had been ruptured fifty-three hours before. The 
condition of the urine also counts against any injury to the 
kidney. The history of constipation before the injury and 
the mass of hard feces in the rectum suggest that constipa- 
tion may be the cause of the abdominal symptoms, and that 
they, and perhaps the blow as well, may be purely coincidences 
and that the real trouble is located somewhere else. 

The cough suggests some trouble in the lungs. It is a well- 
known fact that the pain in pneumonia is often referred by 
children to the abdomen and that distention of tlie abdomen 
is very common in pneumonia at this age. Localized diminu- 
tion of the respiratory sound is often the earliest sign of pneu- 
monia. When associated with dullness, as in this instance, it 



374 CASE HISTORIES IN PEDIATRICS. 

is most suspicious. The relative increase in the rate of the 
respiration over that of the pulse (2 J to i instead of the normal 
4 to I ) in an acute disease with a high temperature is almost 
pathognomonic of pneumonia. The motion of the alae nasi, 
while it points toward trouble in the respiratory tract, does 
not necessarily mean that that trouble is pneumonia. Mo- 
tion of the alae nasi is, moreover, not uncommon when there 
are inflammatory processes in the abdomen. It is, therefore, 
not of much diagnostic importance in this instance. The 
flushing of the cheeks is merely a sign of fever and is not espe- 
cially suggestive of pneumonia, as is often supposed. The 
diminution of the knee-jerk is of but little importance, but 
nevertheless is another point in favor of pneumonia. The 
high leucocyte count is characteristic of pneumonia, but is 
not inconsistent with an inflammatory process in the abdomen 
and hence is of practically no importance in the differential 
diagnosis. The points in favor of pneumonia are so much 
more numerous and fit together so much better than do those 
in favor of an inflammatory process in the abdomen that a 
positive diagnosis of Pneumonia is justified. The abdominal 
symptoms are presumably in part due to the constipation 
and in part secondary to the pneumonia. The blow was 
purely a coincidence. 

Prognosis. The prognosis of pneumonia in children is, 
on the whole, very good. He is a strong boy and at present 
is not any sicker than he would be expected to be. His 
chances ought to be at least as good as the average. He can 
be confidently expected to recover. A certain number of 
children with pneumonia are unfortunate enough to develop 
empyema. He may or may not be one of these. It is 
impossible to tell. 

Treatment. The most important part of the treatment is 
to give him a large supply of fresh air. All the windows in 
his room should be wide open. He can be protected from the 
wind, if necessary, by a screen. This being January, he must 
be warmly covered and will probably need a cap and heaters, 
perhaps mittens. If he is treated in this way his fever will, 
in all probability, not require any treatment. Applications 
to the chest, whether poultices, cotton jackets or mud, can 



DISEASES OF THE BRONCHI, LUNGS AND PLEURAE. 375 

have no effect on the pneumonic process, tend to overheat 
the patient and, if heavy, interfere with the respiration by 
their weight. There are no drugs which have any effect on 
the pneumonic process. His heart is strong. Medicinal 
treatment is, therefore, contra-indicated. 

The treatment of pneumonia by vaccines, whether autog- 
enous or stock, is, in the author's opinion, irrational and, 
consequently, unjustifiable. In the light of our present 
knowledge regarding the different types of pneumococci 
in pneumonia, it is foolish to expect good results from the 
use of stock or polyvalent sera. The results obtained with 
specific sera for types i and ii are, however, very satisfactory, 
while little is to be hoped for from that for type iii. There 
is, of course, no specific serum for group iv, which is the cause 
of a considerable proportion of the cases of pneumonia in 
childhood. Pneumonia in childhood carries, in general, such 
a good prognosis that the serum treatment is not very neces- 
sary at this age. If a good specimen of the sputum from the 
lungs can be obtained, it will be advisable, however, to deter- 
mine the type of organism and, it does not belong to group iv, 
to give him the serum treatment, if serum is available. 

Cough is not likely to be troublesome if he gets plenty of 
fresh air. If it is, and there is no edema of the lungs or 
bronchitis, heroin, in doses of from one twenty-fourth to 
one twelfth of a grain, will probably make him more com- 
fortable and not do any harm. He should be fed once in 
three hours with milk and soft solids, such as simple cereals, 
custards, blanc mange, ice cream and milk toast. Care 
should be exercised in giving him milk because of the con- 
stipation. 

The constipation will probably be relieved by low enemata 
of suds. If they are not sufficient, high enemata of suds, oil 
or glycerin may be tried. If these are unsuccessful, a table- 
spoonful of castor oil or two teaspoonfuls of syrup of senna 
will probably be effectual. 



376 CASE HISTORIES IN PEDIATRICS. 

CASE 114. Matthew L., twenty-six months old, had al- 
ways been unusually strong and vigorous, but very nervous 
and excitable. He had had a little '' cold in the head " for 
two or three days, but had not seemed at all sick. The appe- 
tite was rather poor, February 19, and consequently he was 
not given as much to eat as usual. His bowels moved nor- 
mally just before he went to bed. He was very restless and 
feverish all night and toward morning vomited several large 
curds of milk. He had a severe convulsion about 8.30 a.m. on 
the 20th. The colon was washed out and a considerable amount 
of well-digested, yellow feces obtained. He was given two 
tablespoonfuls of castor oil, which resulted in three large, 
loose, yellow movements which contained a little undigested 
food. He had no more convulsions, but twitched a little 
from time to time. He coughed occasionally, and moving, 
coughing and crying seemed to hurt him. The rectal tem- 
perature had ranged between 104° F., and 104.5° ^* ^^ was 
seen in consultation at 9 a.m., February 21. 

Physical Examination. He was well developed and nour- 
ished. Pallor was marked and there was a slight tinge of 
cyanosis about the lips. He was perfectly conscious, but 
restless and irritable. There was a slight tendency to rigidity 
and he twitched occasionally. There was no stiffness or 
tenderness in the neck. The pupils were equal and reacted to 
light. The alae nasi moved with respiration. The ear drums 
were normal. The tongue was moderately coated. The 
throat was normal. The heart and lungs were normal. The 
liver and spleen were not palpable. The extremities were 
normal. There was no definite spasm of the extremities and 
no paralysis. The knee-jerks were equal and slightly dimin- 
ished. Kernig's sign was absent. There was no enlargement 
of the peripheral lymph nodes, and no eruption. The rectal 
temperature was 104.6° F., the pulse 140, the respiration 70. 
The leucocytes numbered 24,000. 

Diagnosis. The persistence of the high temperature in 
spite of the thorough emptying of the bowels, the practically 
normal character of the movements and the cessation of the 
vomiting rule out all affections of the gastro-intestinal tract. 
The absence of sore throat and eruptions rules out tonsillitis 



DISEASES OF THE BRONCHI, LUNGS AND PLEURAE. 377 

and scarlet fever, while the absence of catarrhal symptoms 
and the leucocytosis exclude influenza. The initial convul- 
sion and the persistence of twitching, together with the slight 
tendency to rigidity, suggest, to a certain extent, some form 
of meningitis, more probably the cerebrospinal. The normal 
mental condition and the absence of all physical signs of 
meningeal irritation, unless the twitching and tendency to 
rigidity be such, practically exclude meningitis. An initial 
convulsion, moreover, is not uncommon at the onset of any 
acute disease in childhood, and a high temperature often 
causes twitching and a tendency to rigidity in nervous chil- 
dren. These points do not count much, therefore, in favor 
of meningitis. The continued high temperature, the slight 
cough, the pain on motion, cough and crying, and, more than 
all, the much greater increase in the rate of the respiration 
than in that of the pulse (2 to i instead of the normal 4 to i), 
make the diagnosis of Pneumonia practically certain in 
spite of the absence of physical signs in the lungs. The move- 
ment of the alse nasi, the slight tinge of cyanosis about the 
lips and the diminution of the knee-jerks, although not of 
much importance, are corroborative of this diagnosis, while 
the leucocytosis is consistent with it. 

Prognosis. The prognosis of pneumonia in childhood is 
very good. In infancy, however, it is a far more serious dis- 
ease. This boy has always been strong and well, is in good 
general condition and probably will not have much lung 
involved. The symptoms of nervous irritability do not make 
the outlook any less favorable. The chances are, therefore, 
very much in favor of his recovery. 

Treatment. The treatment is essentially the same as 
that described in Case 113. The chances of using a specific 
serum in this instance are, however, very small. It is very 
difficult indeed to get sputum from the lungs in babies of this 
age and lung puncture is not justifiable except in extreme 
cases. Moreover, a very la.rge proportion of the cases of 
pneumonia in infancy are caused by group IV. 

The windows must be kept wide open, day and night. 
The cool, fresh air will probably lower the temperature some- 
what, and thus diminish the nervous symptoms. If they 



378 CASE HISTORIES IN PEDIATRICS. 

persist, the temperature must be reduced by bathing. The 
coal-tar products should never be used in pneumonia, either 
to reduce the temperature or to reUeve nervous symptoms. 
The temperature needs to be reduced, not because it is 104.6° 
F., but because in this mstance this degreee of temperature 
causes nervous symptoms. If it did not, it would not be 
necessary to treat it. Sponge baths of alcohol and water, 
equal parts, at 90° F., will probably be sufficient to control 
it. If they do not, fan baths will almost certainly be effec- 
tual. Fan baths are given in this way: The patient is 
stripped and wrapped in cheesecloth. This is then wet with 
water at 100° F. and the patient fanned. The temperature 
is reduced by the evaporation of the water. The cheese- 
cloth is wet from time to time as the water evaporates. 
Children seldom object to this form of bath. If this is 
ineffectual, he may be given a cold pack at from 60° 
F. to 70° F. Children seldom bear tub baths weU, and it 
is, as a rule, wiser not to use them. If necessary, he may 
be given sodium or potassium bromide, in doses of from 
three to five grains, from time to time. There is no indi- 
cation for stimulation at present. 



DISEASES OF THE BRONCHI, LUNGS AND PLEURAE. 379 

CASE 115. David K., eight years old, had had the measles 
when a baby. Since then he had always been well. August 
20 he began to complain of a little pain in his lower left chest, 
which was worse when he ran or played. August 22 he began 
to have a little cough, which was dry and not accompanied 
by pain. After the beginning of the cough the pain in the 
chest ceased, his appetite became poor and he acted weak 
and tired. His mother said that he wanted to sit alone by 
himself instead of playing with the other children. She 
thought that he had been feverish and said that he had sweat 
profusely at night. He was first seen August 30. 

Physical Examination. He was well developed and nour- 
ished, but somewhat pale. There was no dyspnea, except on 
exertion. The tongue was moist with a moderate white coat 
in the center. The throat was normal. The cardiac impulse 
was visible in the fourth space in the left parasternal line. 
The right border of the relative cardiac dullness was about 
two thirds of the distance from the right border of the sternum 
to the right nipple. The upper border of the relative cardiac 
dullness was at the lower border of the second rib. The heart 
sounds were normal in character, but louder to the right of 
the sternum than to the left. The second pulmonic sound 
was considerably louder than the second aortic. The left 
chest moved somewhat less in respiration than the right. 
The intercostal spaces were the same on both sides. There 
was dullness in the left back from the spine to the angle of 
the scapula, below which there was flatness. The whole left 
axilla was flat. There was dullness in the left front from the 
upper border of the third rib to the upper border of the fourth 
rib, below which there was flatness. There was dullness in 
Traube^s space. The respiration was loud and bronchial 
below the upper level of dullness, both in back and in front. 
The voice sounds were increased; the vocal fremitus dimin- 
ished. No rales were heard. Above the level of dullness the 
respiration and voice sounds were normal in character and a 
few fine moist rales were heard. There was a marked sense of 
resistance over the dull and flat areas. There was exaggerated 
vesicular resonance over the whole right chest. The respira- 
tion was loud and distinctly puerile. The voice sounds and 



380 CASE HISTORIES IN PEDIATRICS. 

fremitus were normal. No extraneous sounds were heard. 
The upper border of the liver flatness in the nipple line was at 
the upper border of the seventh rib. The lower border of the 
liver was palpable 2 cm. below the costal border. The spleen 
was not palpable. The dullness was not determined because 
of the dullness in the left chest. The abdomen showed noth- 
ing abnormal. The extremities were normal. There was no 
spasm or paralysis and the knee-jerks were equal and normal. 
There was no enlargement of the peripheral lymph nodes. 
The mouth temperature was 101.2° F., the pulse 130 and the 
respiration 48. 

Diagnosis. The trouble is, of course, located in the left 
chest. The only question is whether there is solidification of 
the lung or an effusion into the pleural cavity. If the trouble 
is in the lung, it is, judging from the history, more probably 
tubercular than pneumonic. The diminution in the motion 
of the left chest and the mere presence of dullness or flatness 
are of no importance in differential diagnosis. The points 
in favor of solidification of the lung are the normal level of 
the intercostal spaces, the loud bronchial respiration and the 
increased voice sounds. The intercostal spaces are, however, 
often level in childhood, even when there is considerable 
fluid in the pleura, because the elastic chest gives as a whole, 
while in the adult the rigid chest wall does not give and the 
intercostal spaces yield. Theoretically, the respiration and 
voice sounds ought not to be transmitted through fluid; 
practically, they often are in childhood. The explanation is 
presumably to be found in the elasticity of the thoracic wall 
at this age. The bronchial character of the respiration in 
pleural effusion is due to the compression of the lung. The 
points in favor of consolidation of the lung are, therefore, not 
as important as they at first appear. 

The points in favor of a pleural effusion are the distribution 
of the dullness and flatness, which follows gravity rather than 
the lobes of the lung, the displacement of the heart to the 
right, the dullness in Traube's space (which means depres- 
sion of the diaphragm), the diminished fremitus, the absence 
of rales and the marked sense of resistance. The distribution 
of the dullness and flatness is not of quite as much importance 



DISEASES OF THE BRONCHI, LUNGS AND PLEURAE. 381 

in this instance as it usually is, because the trouble, being 
tubercular, would not be as likely to be lobar in its distribu- 
tion as would a pneumonia. It may be argued that, if the 
diaphragm is depressed, the spleen ought to be palpable. 
The location of the spleen is such, however, that depression 
of the diaphragm does not displace it. The displacement of 
the heart and diaphragm is positive proof of the presence of a 
pleural effusion. The marked sense of resistance is almost 
positive proof of effusion, as this is practically never felt to 
the same extent over a solid lung. The diminished fremitus 
and the absence of rales are of much less importance, as they 
can be explained in other ways. 

The accentuation of the second pulmonic sound is, of course, 
due to the increased pressure in the pulmonary circulation. 
The physical signs in the right chest are characteristic of 
compensatory emphysema. The upper border of the liver 
flatness is as much below the normal level as the lower border 
is below the costal margin, showing that the liver is not 
enlarged, but merely displaced downward. 

The next point to be decided is whether the effusion is 
serous or purulent. The effusion in this instance is, judging 
from the history, primary, that is, it is not secondary to some 
other acute disease. Primary pleurisy at this age is almost 
always serous; secondary, almost always purulent. The 
sweating is merely a sign of weakness and does not count at 
all in favor of a purulent effusion. The temperature is con- 
sistent with either condition. There is nothing about the 
physical signs which is of any value in differential diagnosis. 
A leucocyte count would probably be of considerable assist- 
ance in diagnosis because there is almost never a leucocytosis 
with a primary serous effusion, and almost always a marked 
leucocytosis when the fluid is purulent. The absence of 
leucocytosis in primary serous effusions is presumably due to 
the fact that they are almost invariably tubercular. The only 
positive method of diagnosis is exploratory puncture. It is 
reasonably safe to make a diagnosis of Serous Pleurisy in 
this instance, however, on the history. 

A skin tuberculin test will aid much in determining whether 
or not the effusion is or is not tubercular. A more certain 



382 CASE HISTORIES IN PEDIATRICS. 

method, however, is by the examination of the fluid obtained 
by exploration or aspiration. There are, as a rule, a large 
excess of lymphocytes in the tubercular cases, and of poly- 
nuclear cells in the acute infectious variety. If the fluid is 
digested before the examination (inoscopy), tubercle bacilli 
can be found in a large proportion of the tubercular cases; 
in fact, more positive results are obtained in this way than 
by animal inoculations. 

An exploratory puncture was done and a serous fluid, which 
contained an excess of lymphocytes and a few tubercle bacilli, 
was obtained. 

Prognosis. There is no danger to life from the effusion if 
it is not allowed to accumulate enough to cause symptoms of 
pressure. It is not an especially serious form of tuberculosis. 
The prognosis is, therefore, that of tuberculosis in general. 

Treatment. The effusion is not causing any symptoms from 
pressure on other organs. It is, therefore, wiser not to with- 
draw it at present. Applications to the chest wall are useless. 
It is unreasonable to expect that diuretics and cathartics will 
draw the fluid from the pleural cavity, in which the pleura is 
inflamed and not in a condition to absorb fluid, rather than 
from the tissues. They cannot be of use, anyway, unless 
liquids are excluded from the diet. It is very unwise to cut 
liquids out of a child's diet, and, moreover, free catharsis is 
very weakening. They cannot, therefore, do much, if any, 
good, and are almost certain to do harm by interfering with 
the ingestion of food and weakening the patient. They 
ought not to be used in this instance. If the fluid increases 
enough to cause symptoms of pressure, or if it does not begin 
to diminish after ten days or two weeks, it should be with- 
drawn. If the chest refills, the aspiration may have to be 
repeated several times. 

He must be kept quiet in bed and well fed. The further 
treatment is that of tuberculosis in general. 



DISEASES OF THE BRONCHI, LUNGS AND PLEURA. 383 

CASE 116. Sophy L. was seen in consultation when four 
and one-half years old. She had always been delicate. Seven 
and one-half weeks previously she was taken suddenly ill 
with a pneumonia involving the whole left lower lobe. She 
was under the care of Dr. G. for a week. The crisis did not 
occur during this time. Dr. G. was then discharged and 
another doctor called in. The crisis is said to have occurred 
on the eighth or ninth day. A week later Dr. G. was again 
given charge of the case. He found the temperature running 
between 103° F. and 104° F. It dropped a little after a few 
days and since then had ranged between 101° F. and 102° F. 
She had had no chills, but had sweat freely, especially about 
the head. She was not short of breath and did not complain 
of pain. She coughed occasionally. Her appetite was good, 
but she was somewhat constipated. She had lost weight 
steadily. She had been up and about the house for ten days. 
An examination of the sputum for tubercle bacilli had been 
negative. 

Physical Examination. She was slight, thin and somewhat 
pale. There was no cyanosis. She cried loudly without 
distress. The cardiac impulse was palpable just to the left 
of the sternum. The impulse was also palpable to the right 
of the sternum and was stronger there than on the left. The 
cardiac dullness extended from 2 cm. inside the right nipple 
to I cm. to the left of the left border of the sternum. The 
heart sounds were louder to the right than to the left of the 
sternum. The sounds were not abnormal. The left side of 
the thorax appeared larger than the right, and moved much 
less than the right in respiration. The left intercostal spaces 
were nearly obliterated. There was flatness in the left chest 
above the third rib in front, the fifth in the axilla and the mid- 
scapula behind. In this area respiration was bronchial, and 
the voice sounds and fremitus slightly increased. Below the 
flat area down to the fifth space in front, the sixth space in 
the axilla and in the whole back there was flat tympany. 
Below this there was loud tympany. In these areas respira- 
tion was diminished, but almost vesicular in character. The 
voice sounds were diminished, but not changed in character. 
The vocal fremitus was absent. There was tympany in 



384 CASE HISTORIES IN PEDIATRICS. 

Traube's space. There was a very marked sense of resistance 
over the whole left chest, more marked in the lower portion 
than in the upper. The right chest was somewhat hyper- 
resonant, except that there was a triangular area of dullness 
in the back, the apex being at the level of the spine of the 
scapula, the side along the back bone and the base along the 
tenth rib, extending outward about two inches. The respira- 
tion was of normal character, but louder than normal over 
the whole right side. The upper border of the liver flatness 
was at the upper border of the sixth rib; the lower border 
was palpable 4 cm. below the costal border in the nipple line. 
The spleen was not palpable. The abdomen was rather full, 
but not tense or tender. The extremities showed nothing 
abnormal. There w^as no general enlargement of the super- 
ficial lymph nodes. The rectal temperature was 100° F., the 
pulse 120, the respiration 35. 

Diagnosis. The history is so characteristic of an empyema 
secondary to pneumonia that it hardly seems necessary to 
consider anything else, unless the physical examination proves 
this supposition to be wrong. Other remote possibilities are 
an unresolved pneumonia, an acute tubercular pneumonia 
which has changed to a chronic condition, and a secondary 
tubercular infection consecutive to a pneumococcus pneu- 
monia. 

The physical signs are, however, confusing. The marked 
displacement of the heart to the right, the enlargement of 
the left chest, the obliteration of the left intercostal spaces, 
and the triangular area of dullness in the right back (Grocco's 
sign) prove that there is something in the left pleural cavity. 
The tympany in the lower portion suggests that this may be 
air. The marked sense of resistance proves that it is fluid. 
It would be almost unheard of, moreover, to have fluid or 
solid lung in the upper part of the chest and air alone in the 
lower. The tympanitic sound is undoubtedly transmitted 
from the abdomen, and the vesicular respiration and normal 
voice sounds from the right side. The bronchial respiration 
and increased voice sounds and fremitus in the upper portion 
suggest strongly that the upper half of the chest is filled by 
solid lung. The marked sense of resistance and the marked 



DISEASES OF THE BRONCHI, LUNGS AND PLEURA. 385 

displacement of the heart, together with the well-known fact 
that in children the respiration and voice sounds, and some- 
times even the fremitus, may be transmitted through fluid if 
the tension is high enough, show conclusively that the upper 
as well as the lower portion of the chest is filled with fluid. 
The bronchial character of the respiration is due to the com- 
pression of the lung, which is presumably squeezed into a 
small mass at the root. The tympany in Traube's space is 
probably also transmitted from the abdomen and does not 
mean that the diaphragm is in its normal position. 

The signs in the right chest are characteristic of a compen- 
satory emphysema. The upper border of the liver flatness is 
slightly lower than normal, but not as much so as the lower 
border. This shows that the liver is enlarged. The enlarge- 
ment is probably due to fatty change, resulting from mal- 
nutrition and toxic absorption, although it may possibly be 
amyloid. 

There is undoubtedly fluid in the left pleural cavity. This 
fluid accumulated after pneumonia, and the patient is a child. 
The chances are, therefore, at least nineteen out of twenty 
that it is purulent rather than serous. The absence of chills 
does not count against, nor the presence of sweating for, a 
purulent effusion, because chills are rather unusual with an 
empyema at this age, and sweating is common in all conditions 
of weakness. The diagnosis of Purulent Pleurisy is, there- 
fore, justified without an exploratory puncture. 

Prognosis. If the chest is not opened she will almost cer- 
tainly fail steadily and finally die. There is, however, a small 
chance that" the pus may eventually find a way out for itself 
or become encapsulated and absorbed. In either case, she 
is certain to be left with a very greatly deformed chest. If 
the chest is opened at once she will almost certainly recover, 
because her general condition is surprisingly good under the 
circumstances and the evidences of septic absorption com- 
paratively slight. It is six weeks since the appearance of the 
effusion, it is very large, the lung is much compressed and 
probably more or less bound down by adhesions. The 
chances are, therefore, that it will not fully expand and that 
she will be left with some deformity. 



386 CASE HISTORIES IN PEDIATRICS. 

Treatment. The only rational treatment in this instance 
IS the opening and draining of the pleural cavity. It is true 
that in rare instances recovery ensues in pneumococcus 
empyema after tapping. This happens so seldom, however, 
that it cannot be regarded as a justifiable procedure. The 
almost invariable result is that the pus reaccumulates and 
that the chest has to be finally opened. In the meantime the 
general condition has been further impaired as the result of 
the continued septic absorption, and the lung has been further 
compressed and its complete expansion rendered more diffi- 
cult. The long duration and the large amount of the effusion 
in this instance make the chances of cure from aspiration 
even less than the average. She should, therefore, be operated 
on at once. The author believes that resection of a rib gives 
much better results than simple incision. A resection should 
certainly be done in this instance because, on account of the 
duration of the process, there are probably large clots and 
masses of caseous material which could not be satisfactorily 
cleaned out through an incision. 



DISEASES OF THE BRONCHI, LUNGS AND PLEURAE. 387 

CASE 117. Joseph C. was the only child of healthy 
parents. There was no tuberculosis in either family and 
there had^been no known exposure to it. He was born a 
month before he was expected. He was fed from the first 
on simple dilutions of milk with water. His digestion was 
good, but he was always anemic. He had pneumonia about 
the middle of December, but was considered well early in 
January. His temperature rose again January 22 and the 
respiration became rapid and difficult. His physician found 
dullness with bronchial respiration and voice sounds over 
the whole left chest. Although the heart was in normal 
position, he suspected the presence of fluid and tapped him 
twice in the lower back and once in the lower axilla, but 
obtained nothing. From this time on he ran an irregular 
temperature, which varied between normal and 105° F. 
The respiration continued rapid and he had a troublesome 
cough. He took his food fairly well and had no disturbance 
of the digestion but, nevertheless, lost weight steadily. He 
was seen in consultation March 8, when thirteen and one- 
half months old. 

Physical Examination. He was long, thin, feeble and very 
pale. The anterior fontanelle was one cm. in diameter. 
The bones of the skull overlapped a little. He had eleven 
teeth. The ears and throat were normal. There was a 
moderate rosary. The cardiac impulse was felt distinctly in 
the second, third and fourth interspaces. The left and 
upper borders of dullness could not be determined because 
of the dullness in the left chest. The right border was two 
cm. to the right of the median line. The action was regular 
and the sounds strong. There was a systolic murmur at 
the base of the heart and a venous hum in the neck. The 
second sound at the pulmonic area was slightly accentuated. 
The left side of the chest moved less than the right. There 
was no bulging of the intercostal spaces. There was flat- 
ness with a very marked sense of resistance in the left front 
and axilla above the fifth rib and in the back above the spine 
of the scapula. The respiration and voice sounds were loud 
and bronchial in the flat area while the tactile fremitus was 
diminished. There was slight tympany over the rest of the 



388 CASE HISTORIES IN PEDIATRICS. 

left side, the respiration and voice sounds being diminished 
and bronchial in character. There was tympany in Traube's 
space. Grocco's sign was absent. The right chest was 
hyperresonant and the respiration exaggerated, but vesicular. 
The abdomen was large, lax and tympanitic. The lower 
border of the liver was palpable one cm. below the costal 
border in the nipple line. The spleen was not palpable. 
The extremities were normal. There was no spasm or paral- 
ysis. The knee-jerks were equal and normal. Kernig's sign 
was absent. The genitals were normal. There was no en- 
largement of the peripheral lymph nodes. The rectal temp- 
erature was 99.4° F. ; the pulse, 120; the respiration, 35. 

The leucocyte count was 24,000. 

Diagnosis. The trouble in this instance is unquestion- 
ably located in the upper portion of the left chest. The only 
conditions which need to be considered are solidification of 
the lung, presumably due to an unresolved pneumonia, and 
an accumulation of fluid, almost certainly pus. The ab- 
normalities in the physical signs in the lower portion of the 
chest are of no importance in differentiating between them, 
the tympany being transmitted from the abdomen, the 
diminished respiration being due to the diminution in the 
expansion on that side, while the bronchial respiration may 
be transmitted from either a solid or a compressed lung. 
Grocco's sign would, of course, be absent with an accumula- 
tion of fluid in the upper chest. The systolic murmur at 
the base of the heart and the venous hum in the neck are 
both signs of the evident anemia. The accentuation of the 
second pulmonic sound is due to the increased pressure in 
the pulmonary circulation. The flatness is consistent with 
either condition. Loud bronchial respiration and voice sounds 
are heard so commonly over accumulations of fluid in infancy 
that they do not count much in favor of solidification of the 
lung. The absence of bulging of the intercostal spaces is 
somewhat against an accumulation of fluid, but is not of 
much importance, because bulging of the intercostal spaces 
is unusual in infancy, the chest yielding as a whole first. 
The location of the flat area, which corresponds fairly closely 
to the upper lobe, and the normal position of the heart are 



DISEASES OF THE BRONCHI, LUNGS AND PLEURA. 389 

Strong evidence in favor of solidification of the lung. The 
long duration of the illness, the marked irregularity of the 
temperature, the diminution of the tactile fremitus, the leu- 
cocytosis and, more than all else, the very marked sense of 
resistance, count, on the other hand, in favor of an accumu- 
lation of pus. If there is an empyema it is, of course, en- 
capsulated in the upper portion of the chest, the lung below 
being bound to the parietal pleura. The pressure of the 
fluid would be exerted chiefly on the upper lobe which 
would be much compressed before the lower portion would 
be affected. The location of the flat area would, therefore, 
naturally correspond fairly closely to that of the upper lobe. 
The absence of displacement of the heart does not count as 
much against an empyema as at first appears, because with an 
encapsulated empyema at the apex it would almost certainly 
be caught in the adhesions below and held in position. The 
evidence seems, therefore, much in favor of an encapsulated 
empyema at the apex, certainly enough so to demand an 
exploratory puncture. 

A needle was introduced high in the axilla, just behind the 
anterior axillary line, and pus withdrawn, thus justifying the 
diagnosis of Encapsulated Empyema. 

Prognosis. The baby has always been anemic and is in 
very poor general condition. The chances are, therefore, 
very much against his recovery, even if he is operated upon 
immediately. The facts that the heart is not displaced and 
that the fluid is retained in the upper portion of the chest 
show that the lung must be bound down by very firm adhe- 
sions. The chances are, therefore, that the lung will not 
fully expand and that, if he recovers, he will be left with 
some deformity of the chest. 

Treatment. The treatment is the immediate resection of 
a rib as low down as is consistent with reaching the cavity. 
Drainage will be better in this way than if a rib is removed 
higher up. (See Case ii6.) 



390 CASE HISTORIES IN PEDIATRICS. 

CASE Il8. Jeremiah M. was five years old. His parents 
and two other children were living and well. There had been 
no deaths or miscarriages. There was no tuberculosis in the 
family and there had been no known exposure to it. He had 
been perfectly well until he had the measles, five weeks before 
his admission to the Children's Hospital. This was followed 
in two weeks by pneumonia. There had been no drop in the 
temperature since then. The cough had continued, but the 
pain in the side, which was very troublesome at first, had 
ceased. He was able to take but little nourishment, had 
frequent attacks of dyspnea and slept very poorly. 

Physical Examination. He had lost much weight and color. 
He was clear mentally, but apathetic. He was able to lie 
down. The alae nasi moved with respiration. The mem- 
branse tympanorum were normal. The throat was normal, 
the tongue but little coated. The left chest moved much less 
than the right. The cardiac impulse was indistinctly pal- 
pable in the fourth space, just outside the left nipple line. 
The right border of the cardiac dullness was three cm. to the 
right of the median line; the upper and left borders could 
not be determined because of the dullness in the left chest. 
The action was regular. The heart sounds were louder to 
the left than to the right of the sternum and were of fair 
strength. The second sound at the pulmonic area was 
slightly accentuated. There were no murmurs. The right 
chest was slightly hyperresonant and the respiratory sound 
was louder than normal. There was flatness with a marked 
feeling of resistance in the left axilla above the sixth rib, 
below which there was tympany continuous with that in 
Traube's space. There was moderate dullness over the 
middle third of the left scapula. The rest of the left chest was 
slightly dull. The respiration was much diminished in the 
flat area and bronchial in character. It was somewhat 
diminished over the rest of the left chest, but nearly normal 
in character. The voice sounds were diminished and bron- 
chial in the flat area; of normal intensity, but slightly 
bronchial, elsewhere. The tactile fremitus could not be deter- 
mined, because he would neither speak loudly nor cry. There 
were a few fine, high-pitched moist rales in the left front and 



DISEASES OF THE BRONCHI, LUNGS AND PLEURAE. 39I 

an occasional medium moist r^le throughout the back. The 
abdomen was sunken and tympanitic. The upper border of 
the Hver flatness in the nipple line was at the upper border 
of the sixth rib; the lower border was not palpable. The 
spleen was not palpable. The extremities were normal and 
there was no spasm, paralysis or disturbance of the deep 
reflexes. There was no enlargement of the peripheral lymph 
nodes. The rectal temperature was 102° F.; the pulse, 132; 
the respiration, 40. 

The urine was cloudy, acid in reaction, of a specific gravity 
of 1028, and contained no albumin or sugar. The sediment 
consisted of amorphous urates. 

The leucocyte count was 23,400. 

Diagnosis. Reasonable explanations for the persistence 
of the fever and other symptoms are an extension of the 
pneumonia, the development of a purulent pleurisy, some 
incidental complication, or that the trouble was not pneu- 
monia, as supposed, but tuberculosis. The absence of any 
physical signs of disease outside of the lungs and the normal 
condition of the ears and urine rule out all incidental compli- 
cations. His good condition before the onset of the illness, 
the absence of any signs of tuberculosis elsewhere, the rarity 
of acute tubercular pneumonia at this age and the fact that 
the signs in the lungs are more consistent with another con- 
dition rule out tuberculosis. The diagnosis lies, then, between 
solidification of the lung, due to an extension of the pneu- 
monic process, and a purulent pleurisy. Fever, rapid pulse 
and respiration, motion of the alae nasi, cough, diminished 
mobility on the left side and leucocytosis are common to both 
diseases and hence of no aid in distinguishing between them. 
The flatness in the axilla is consistent with either condition, 
as is the bronchial character of the respiration. The marked 
diminution in the intensity of the respiratory and voice 
sounds is more characteristic of an accumulation of fluid, but 
can occur in solidification of the lung if a bronchus is ob- 
structed. The bronchial character of the respiration and 
voice sounds may be due to pneumonic solidification of the 
lung or to compression of the lung by fluid. These signs 
are, therefore, of but little assistance. The marked sense of 



392 CASE HISTORIES IN PEDIATRICS. 

resistance, however, counts strongly in favor of an accumula- 
tion of fluid, more strongly than any other point counts in 
favor of pneumonia, so strongly, in fact, as to justify a prob- 
able diagnosis of this condition. The normal position of the 
heart and the tympany in Traube's space prove that there 
cannot be any large accumulation of fluid in the pleural 
cavity. Small quantities of fluid are usually situated, more- 
over, in the lower back rather than in the axilla. If there is 
fluid present, it must, therefore, be encapsulated. The sense 
of resistance and the diminution in the respiration are more 
marked than would be expected from an encapsulated empy- 
ema of no greater size than that indicated by the area of 
flatness in the axilla. The location of this area is that in 
which the signs of interlobar empyema are usually most 
marked. An accumulation of fluid between the lobes, reach- 
ing the surface in the axilla, will account for the marked sense 
of resistance and the diminution in the respiration. The 
greater dullness under the middle third of the scapula is 
corroborative evidence in favor of this supposition. A 
diagnosis of Interlobar Empyema is, therefore, a reasonable 
one. The slight dullness over the rest of the left chest is 
probably due to thickening of the pleura; the diminished 
respiration, to thickening of the pleura and the defective 
expansion on that side; the slightly bronchial character of 
the respiration, to partial compression of a portion of the lung ; 
the rales, to defective expansion and slight congestion. The 
tympany in the lower axilla is undoubtedly transmitted from 
the abdomen. 

Whenever the physical signs point as strongly to a purulent 
pleurisy as they do in this instance, an exploratory puncture 
should be done at once. A needle was, therefore, introduced 
into the fifth left space in the mid-axillary line and pus 
obtained, thus confirming the diagnosis. 

Prognosis. If the chest is not opened he will almost cer- 
tainly fail steadily and finally die. There is a small chance 
that the pus may break through into a bronchus or be 
absorbed. In either case he will be left with a badly damaged 
lung and probably with a deformed chest. If the chest is 
opened at once he will almost certainly get well, because his 



DISEASES OF THE BRONCHI, LUNGS AND PLEURA. S93 

general condition is fair and the evidences of septic absorp- 
tion comparatively slight. There being but little compres- 
sion of the lung, and the pus being between the lobes where, 
if adhesions form, they will do no harm, he can be expected 
to recover with a practically normal chest. 

Treatment. The only rational treatment in this instance 
is the opening and draining of the pleural cavity. It is true 
that in rare instances recovery ensues in pneumococcus em- 
pyema after tapping. This happens so seldom, however, 
that it cannot be regarded as a justifiable procedure. The 
almost invariable result is that the pus reaccumulates and 
that the chest has to be finally opened. In the meantime, 
the general condition has been further impaired as the result 
of the continued septic absorption, and the lung has been 
further compressed and its complete expansion rendered more 
difficult. He ought, therefore, to be operated on at once. 
Resection of a rib allows much freer drainage than does 
simple incision and is, therefore, the preferable procedure. 



394 CASE HISTORIES IN PEDIATRICS. 

CASE 119. Charles C, three years old, entered the Chil- 
dren's Hospital, February 5, because of a hemorrhage from 
his stomach. He was well developed and nourished, but 
very pale. There was a venous hum in the neck and a sys- 
tolic murmur at the pulmonic area. The left border of the 
cardiac dullness was six cm, to the left and the right border 
two and one-half cm. to the right of the median line, while 
the upper border was at the middle of the third rib. The 
lungs were normal. The upper border of the liver flatness 
was in the fifth space in the nipple line ; the lower border was 
palpable three cm. below the costal border in the same line. 
The spleen was palpable four cm. below the costal border. 
The abdomen was normal and there was no edema. 

Examination, February 10, showed a little puffiness of the 
eyelids. There was dullness on the right side below the angle 
of the scapula behind and the sixth rib in the axilla, extend- 
ing forward as far as the anterior axillary line. The respir- 
atory and voice sounds were diminished in this area, but 
not changed in character. The tactile fremitus was slightly 
diminished and the sense of resistance increased. The left 
border of the cardiac dullness was as before, and the lower 
border of the liver was in the same position. There was 
shifting dullness and a slight fluid wave in the abdomen. 
The diagnosis of effusion in the right pleural cavity was 
made, a needle introduced in the eighth space in the poste- 
rior axillary line and about two ounces of bloody serum with- 
drawn. He began to breathe badly during the afternoon and 
slept but little that night, although supported by pillows. 
The physical examination, February 11, v/as as follows: 

Physical Examination. His breathing was difficult and 
labored and he was unable to lie down. There was, how- 
ever, no cyanosis. The right side of the chest moved but 
little in respiration, but it did not appear larger than the 
left and there was no bulging of the intercostal spaces. There 
was tympany over the whole right front and over the back 
below the angle of the scapula and outside of the inner border 
of the scapula, where there was dullness. The respiration 
was somewhat diminished over the whole side, amphoric in 
character in the tympanitic area, bronchovesicular in the dull 




Charles C. Case 119. 



DISEASES OF THE BRONCHI, LUNGS AND PLEURAE. 395 

area. The voice sounds were ever5rwhere diminished, but 
bronchial in character. The tactile fremitus was absent. The 
sense of resistance was diminished. The coin sound was 
present, but there was no succussion sound. The right 
border of the cardiac dullness was at the left border of the 
sternum ; the left border, eight cm. to the left of the median 
line. The upper border of the liver flatness, in the nipple 
line, was just above the costal border. The liver was pal- 
pable three cm. below the costal border in the nipple line. 
The rectal temperature was 102.8° F.; the pulse, 160; the 
respiration, 60. 

Diagnosis. There can be no doubt as to the diagnosis of 
Pneumothorax with collapse of the lung. The tympanitic 
percussion note, the amphoric respiration, the diminution in 
the voice sounds, the absence of fremitus, the diminished 
sense of resistance and the coin sound are all characteristic 
of this condition. The facts that the right side moves in 
respiration, that there is no enlargement of that side and no 
bulging of the intercostal spaces, that the respiratory sound 
is not much diminished and that there is not much displace- 
ment of the heart and liver show that the opening from the 
lung into the pleural cavity is still patent, that is, that it is 
an open pneumothorax. The absence of the succussion sound 
shows that there is little, if any, fluid in the pleural cavity. 
It is probable that the lung was pricked with the needle 
during the aspiration the day before and that the pneumo- 
thorax is the result. The diagnosis of pneumothorax is con- 
firmed by the accompanying Roentgenograph. 

Prognosis. The pneumothorax being due to a mechanical 
injury to the lung and not to disease, the prognosis is good. 
The opening will almost certainly close in the course of one 
or two days and the air be absorbed inside of two weeks. 

Treatment. There is no treatment for the pneumothorax. 
It is useless to withdraw the air while the opening into the 
lung is still patent; it will be unnecessary after it is closed. 
Treatment, as far as it is directed to the pneumothorax, 
must, therefore, be symptomatic and for comfort. That of 
the original disease may have to be modified, but need not be 
interrupted. 



396 CASE HISTORIES IN PEDIATRICS. 

CASE 1 20. i rank H. was an only child. His mother 
was alive and well, his father had been dead some years. 
The cause of his death was not known. There was no tuber- 
culosis in either family and there had been no known expo- 
sure to it. He was born at full term, after a normal labor, 
w^as nursed by his mother and was perfectly well until he 
was seven and one-half years old, when a tumor was discov- 
ered in the scrotum. The right testicle, with a tumorous 
mass, was removed a few months later at the Boston City 
Hospital by Dr. F. B. Lund. Dr. F. B. Mallory reported that 
the mass was a malignant mixed tum.or. He remained w^ell 
for two years, when he had pneumonia of the left lower lobe, 
which cleared up entirely. This was followed, a few months 
later, by w^hooping-cough. His appetite had been poor and 
he had failed steadily in weight and strength since the 
pneumonia. A week before he entered the Children's Hos- 
pital, when ten years old, he began to have pain in the left 
chest, which was increased by a deep breath. The pain was 
followed, in a few days, by shortness of breath. He had but 
little cough, however, and raised nothing. He had had no 
hemoptysis, night sweats, dysphagia, abdominal pain or 
swelling of the ankles, and had been up and about the house. 

Physical Examination. He was well developed, but poorly 
nourished and moderately pale. His tongue was somewhat 
coated, his throat normal. The cardiac impulse was pal- 
pable in the fifth left space, seven cm. to the left of the median 
line. The upper and left borders of the cardiac dullness 
could not be determined because of the flatness in the left 
chest; the right border was three cm. to the right of the 
median line. The action was regular and the sounds normal. 
The left side did not move with respiration and the inter- 
costal spaces were somewhat less distinct than on the right. 
The circumference of the two sides at the level of the nipples 
was, however, the same. There was flatness over the whole 
left side of the chest and in Traube's space. The sense of 
resistance was much increased. The respiratory and voice 
sounds were diminished and bronchial in character. The 
tactile fremitus was absent. No rales were heard. The right 
side was hyperresonant and the respiratory sound was exag- 



DISEASES OF THE BRONCHI, LUNGS AND PLEURA. 397 

gerated. The upper border of the liver flatness was at the 
upper border of the fifth rib in the nipple line and of the sixth 
rib in the mid-axillary line. The lower border was pal- 
pable three and one-half cm. above the anterior superior 
spine, seven cm. below the costal border in the nipple line 
and twelve and one-half cm. below the tip of the ensiform. 
It ran under the left costal border just inside the left ante- 
rior axillary line. The surface was smooth, except in the 
epigastrium, where there was a protrusion about three cm. 
in height and seven cm. by three cm. in diameter. The 
spleen was not palpable. There were no signs of fluid in 
the abdomen and no other masses were felt. The super- 
ficial veins of the abdomen and of the left side of the chest 
were dilated. The left testicle was normal. There was a 
scar on the right side of the scrotum, which was empty. 
The extremities were normal. There was no spasm or paraly- 
sis. The knee-jerks were equal and normal. Kernig's sign 
was absent. There was no enlargement of the peripheral 
lymph nodes. The mouth temperature was ioo°F.; the 
pulse, 120; the respiration, 40. 

The urine was clear, acid in reaction, of a specific gravity 
of 1032 and contained no albumin or sugar. 

Diagnosis. When it is taken into consideration that the 
enlargement of the liver followed the removal of a malig- 
nant tumor of the testicle, that it is nodular and not accom- 
panied by jaundice, ascites or enlargement of the spleen, 
there can be no question as to the diagnosis of Sarcoma of 
THE Liver. The condition in the left chest is more obscure. 
The immobility of the left side, the partial flattening of the 
intercostal spaces, the flatness over the whole side and in 
Traube's space, the diminished respiration and voice sounds, 
the absence of fremitus and the increased sense of resistance 
seem, at first thought, to prove conclusively that there is a 
large accumulation of fluid in the left pleural cavity. The 
heart is, however, not displaced more than one-half of a 
cm., but this may be, of course, because it is bound down by 
adhesions. Judging from the position of the lower border 
of the liver, the dullness in Traube's space may be equally 
well due to the enlarged liver. Grocco's sign is absent. 



398 CASE HISTORIES IN PEDIATRICS. 

These are strong points against a pleural effusion. Is it 
possible to explain the other signs in any other way? It 
certainly is. A massive tumor involving the whole lung 
will give flatness and a marked sense of resistance over the 
whole side. If the bronchi are partially obliterated, the 
respiratory and voice sounds will be diminished and bron- 
chial in character and the fremitus absent. The heart will 
not be displaced and Grocco's sign will be absent, as in this 
instance. The enlargement of the superficial veins of the 
left side of the chest also points strongly to a new growth in 
the lung. The diagnosis of a massive Sarcoma of the Lung 
is, therefore, certain. 

Prognosis. The prognosis is absolutely hopeless. He 
will probably not live more than a few weeks, certainly not 
more than a few months. 

Treatment. Nothing can be done, except to make him as 
comfortable as possible. 



SECTION VIII. 
DISEASES OF THE HEART AND PERICARDIUM. 

CASE 121. Dillaway P., the second child of healthy par- 
ents, was delivered by version at full term, was apparently 
normal at birth and weighed seven and one-half pounds. He 
was very badly fed during his first year and suffered from 
indigestion during his second year. A murmur was discovered 
in his heart during a routine examination when he was ten 
months old. When he was two years old he had influenza, 
followed by pneumonia. Since then he had been well, except 
for symptoms of adenoids and occasional nosebleeds, which 
were probably due to them, until the last few months, during 
which he had had a recurrence of his indigestion. He was 
seen when four years old. He had never been short of breath 
or cyanotic. 

Physical Examination. He was fairly developed and nour- 
ished and looked well. His color was good, but when he 
cried there was, perhaps, a slight tinge of cyanosis in the 
cheeks. His throat was normal, his tongue moderately coated. 
There was no deformity of the chest. The cardiac impulse 
was visible and palpable in the fifth space in the nipple line, 
6| cm. to the left of the median line (normal is in fourth space, 
6 cm. to left of median line). The left border of the relative 
cardiac dullness corresponded to the impulse. The upper 
border of the relative dullness was at the upper border of the 
second rib (normal is in the second space), and the right bor- 
der 3 cm. to the right of the median line (normal is 2^ cm.). 
There was no dullness under the manubrium. The action 
was regular; the rate, 90 (normal). A very distinct thrill was 
felt in the second left interspace. It was also palpable, but 
much less distinctly, over the rest of the precordia. The 
first sound was everywhere distinct, but was followed over 
the whole precordia by a loud, rough murmur, loudest in the 
second left interspace. This murmur was also audible in the 

399 



400 CASE HISTORIES IN PEDIATRICS. 

neck and over the whole chest, back and front. The second 
pulmonic sound was much louder than the second aortic, so 
much louder that it was undoubtedly accentuated. The 
lungs and abdomen were normal. The liver and spleen were 
not palpable. The extremities were normal. There was no 
clubbing of the fingers or toes. There was no spasm or pa- 
ralysis. The knee-jerks were equal and normal. There was 
no enlargement of the peripheral lymph nodes. 

Diagnosis. This boy undoubtedly has a cardiac lesion. 
The first thing to be decided is whether it is congenital or 
acquired; next, to determine, if possible, what the lesion is. 
The points in favor of a congenital lesion in this instance are 
the fact that the murmur was discovered when he was only 
ten months old, before he had had any disease likely to be 
accompanied by endocarditis; the slight enlargement of the 
heart in comparison with the intensity of the murmur; and 
the location of the greatest intensity of the murmur and of the 
thrill and their distribution, which do not correspond to those 
of any of the acquired lesions. The points against a congenital 
lesion are the absence of bulging of the precordia and of all 
the usual signs of interference with the oxygenation of the 
blood. There is, however, no reason for bulging of the pre- 
cordia when the heart is no more enlarged than in this 
instance, and it is perfectly possible to have congenital lesions 
which from their nature, or from the presence of compensa- 
tory lesions, do not interfere with the oxygenation of the 
blood. A positive diagnosis of Congenital Heart Disease 
is, therefore, justified. 

It is impossible during life to make a certain diagnosis of 
the exact lesion in congenital heart disease, although a prob- 
able diagnosis is often possible. In this instance the location 
of the maximum intensity of the murmur and of the thrill in 
the second left interspace and the transmission of the murmur 
into the neck point strongly to a narrowing of the pulmonic 
orifice. The absence of all signs of deficient oxygenation of 
the blood shows that there must be some compensatory lesion. 
The accentuation of the second pulmonic sound suggests that 
this lesion is an open ductus arteriosus. 

Prognosis. He has reached the age of four years and has 



DISEASES OF THE HEART AND PERICARDIUM. 401 

passed through a pneumonia without the appearance of any 
symptoms referable to the heart, has perfect compensation 
with but little cardiac enlargement, and has developed nor- 
mally. It seems reasonable to suppose, therefore, that his 
cardiac lesion will not interfere with his growth and develop- 
ment and that he will reach adult life and perhaps attain old 
age. The prognosis in this instance is as good, if not better, 
than it would be if he had an acquired lesion. 

Treatment. He requires no treatment at present, except 
that it will be advisable for him to avoid continued, excessive 
exertion. If failure of compensation develops, the treatment 
will be that of failure of compensation in general. 



402 CASE HISTORIES IN PEDIATRICS. 

CASE 122. Francis H. was the third child of healthy 
parents. The other children were alive and well and there 
had been no miscarriages. He was born at full term, after 
a normal labor, and weighed nine pounds. He was somewhat 
cyanotic at birth and it was hard to establish respiration. 
The trained nurse who had charge of him at first did not 
notice that he was cyanotic. When his mother took charge 
of him, when he was a month old, she noticed, however, that 
he became a little blue on crying. She thought that the 
cyanosis on crying had not increased since then and that his 
color was good at other times. She had also noticed that he 
breathed quickly when he was asleep and that he had a 
tendency to keep his mouth open. He had a "funny little 
cough" in the beginning, which improved somewhat after 
the first week. She said that recently he had coughed "like 
an old man." He had been fed on modified cows' milk since 
he was a week old, but had had no disturbance of the diges- 
tion. He had had no illnesses. He was seen in consultation 
when three months old. 

Physical Examination. He was fairly developed and 
nourished. When quiet, he was pale, except that the hands 
and feet were a little bluish. When he cried, he was every- 
where deeply cyanotic. The anterior fontanelle was level. 
The pupils were equal and reacted to light. The mouth and 
throat were normal, and the tongue was clean. The chest 
was of good shape. The cardiac impulse was not visible, but 
was indistinctly palpable in the fourth space, six cm. to the 
left of the median line. There was no thrill. The left 
border of the cardiac dullness corresponded to the impulse. 
The upper border was under the second rib ; the right border, 
two cm. to the right of the median line. The action was 
perfectly regular and the sounds were strong. The second 
pulmonic sound was normal. The first sound in the third and 
fourth left spaces was at times followed by a short, blowing 
murmur, which was not transmitted. No murmurs were 
heard elsewhere. The lungs were normal. The lower border 
of the liver was palpable three cm. below the costal border in 
the nipple line. The spleen was not palpable. The abdo- 
men was normal. There was no clubbing of the extremities. 



DISEASES OF THE HEART AND PERICARDIUM, 4O3 

There was no spasm or paralysis. The knee-jerks were equal 
and normal. There was no enlargement of the peripheral 
lymph nodes. He weighed ten pounds. 

Diagnosis. The cyanosis and the cardiac murmur being 
the only abnormal physical signs, it is evident that the trouble 
is located in the heart. The cyanosis proves that the condi- 
tion is not functional, but organic. The facts that he is but 
three months old, that he has been cyanotic since he was a 
month old and probably since birth, that he has had no 
illnesses to cause endocarditis, that the heart is not enlarged, 
that the second pulmonic sound is not accentuated, although 
the murmur is in the mitral area, and that there is no enlarge- 
ment of the liver and spleen or edema of the lungs or extremi- 
ties, in spite of the cyanosis, are sufficient to show that the 
lesion in the heart is not acquired. It must, therefore, be 
congenital. The combination of cyanosis and a cardiac mur- 
mur without enlargement of the heart, weakening of the heart 
sounds and evidences of passive congestion in other organs is, 
moreover, characteristic of Congenital Heart Disease. 

It is never possible to make a positive diagnosis as to the 
exact location of the lesion in congenital heart disease. The 
location of the murmur and the absence of enlargement of 
the heart and of changes in the second sounds point strongly 
in this instance, however, to a defect in the ventricular 
septum. The slight intensity of the murmur is consistent 
with either a very small or a large opening. The deepness 
of the cyanosis on exertion makes it almost certain that it is 
a large one. 

Prognosis. It is impossible to more than guess how long 
he will live. Judging from the intensity of the cyanosis when 
he cries, the rapidity of the respiration and the frequent cough, 
it is probable that he will not live more than a year. He may 
die suddenly at any time and can hardly be expected to 
survive any acute disease of the lungs. He may, however, 
live for a number of years. 

Treatment. There is nothing to do for him at present, 
except to take good care of him. If evidences of failure of 
compensation develop, the treatment will be that of failure 
of compensation in general. 



404 CASE HISTORIES IN PEDIATRICS. 

CASE 123. Elic S. was born one month before he was 
expected, after a normal labor, and weighed three pounds. 
There had been one previous miscarriage. Two younger 
children were well. Jaundice appeared a few days after 
birth, but disappeared in a week. He was breast-fed for nine 
months and did well. He had had no disturbances of diges- 
tion since then. He had scarlet fever at two years and 
whooping-cough at three years. His mother noticed, when 
he was four months old, that his lips, cheeks and nails were 
bluish and that at times the whole body was blue. The 
cyanosis increased rapidly, so that after a short time there 
was always some general cyanosis present. The intensity 
of the cyanosis varied, however, from time to time. The 
cyanosis was increased by exertion, exposure to cold and 
excitement. He had always been weak muscularly and had 
never been able to walk far without getting out of breath. 
He was able to sleep with one pillow and had never had any 
convulsions, edema or pain. His appetite and digestion were 
good. He was bright and happy; in fact, seemed perfectly 
normal, except for the cyanosis and dyspnea on exertion. 
He was seen when five years old. 

Physical Examination. He was fairly developed and 
nourished, but somewhat flabby muscularly. He was per- 
fectly normal mentally, but restless and excitable. He was 
able to lie down fiat without discomfort. There was marked 
general cyanosis, which was greater in the extremities and 
lips than elsewhere. The conjunctivae were slightly discolored 
from the cyanosis. There was no bulging of the precordia. 
The cardiac impulse was palpable in the fourth space in the 
nipple line, six and one-half cm, to the left of the median line. 
The left border of the cardiac dullness corresponded to the 
impulse. The upper border of dullness was at the upper 
border of the third rib. The right border was four cm. to the 
right of the median line. The action was regular. The first 
sound was somewhat short. The second pulmonic sound 
was louder than the second aortic, but no louder than would 
be expected at this age. No abnormal sounds were heard. 
There was no thrill and no dullness under the manubrium. 
The lungs showed nothing abnormal. The thymus was not 




Normal hand. 




Clubbing of the fingers in congenital heart disease. 



DISEASES OF THE HEART AND PERICARDIUM. 405 

palpable in the suprasternal space. There was no increased 
dullness over the upper dorsal spinous processes and no 
change in the respiration or voice sounds in this area. The 
abdomen was normal. The upper border of the liver flatness 
was at the lower border of the fifth rib in the nipple line. The 
liver and spleen were not palpable. The extremities were nor- 
mal, except for marked clubbing both of the fingers and of the 
toes. There was no edema. There was no spasm or paralysis. 
The knee-jerks were equal and normal. Kernig's sign was 
absent. There was no enlargement of the peripheral lymph 
nodes. 

The urine was clear in color, acid in reaction, of a specific 
gravity of 1015, and contained no albumin, sugar or acetone. 
The sediment contained merely a few small round and squa- 
mous cells. 

Blood. 

Hemoglobin, 140% (Sahli) 

Red corpuscles, 11,376,000 

White corpuscles, 12,000 

Small mononuclears, 27% 

Large mononuclears, 5% 

Polynuclear neutrophiles, 68% 

There was no achromia, polychromatophilia or poikilocytosis, 
and no nucleated red cells were seen. 

Diagnosis. The chief abnormalities in this instance are 
the cyanosis, the clubbing of the extremities and the poly- 
cythemia. The normal condition of the lungs and the 
intensity of the polycythemia exclude disease of the lungs 
as the cause of the symptoms, while the absence of all signs of 
enlargement of the tracheo-bronchial lymph nodes and thy- 
mus and of pressure on other organs by them shows that they 
cannot be the cause. The onset of the cyanosis when the 
boy was still on the breast and the absence of all signs of 
indigestion is much against an enterogenous cyanosis, which 
is, moreover, not accompanied by clubbing of the extremities 
and polycythemia. Methemoglobinemia from drugs can 
also be excluded for the same reasons. Chronic polycy- 
themia with cyanosis and enlargement of the spleen (ery- 
thremia or erythrocytosis megalosplenica) can be ruled out 



406 CASE HISTORIES IN PEDIATRICS. 

on the age of the child, the absence of the peculiar bluish-red 
color, the absence of enlargement of the spleen and the 
absence of a polynuclear leucocytosis and of nucleated red 
cells. The cause of the symptoms must be, therefore, some 
Congenital Cardiac Malformation. The enlargement of 
the heart to the right is corroborative evidence in favor of this 
diagnosis. The absence of a murmur does not count much 
against it, because it is a well-known fact that there may be 
no murmur in congenital heart disease, even when other signs 
are marked. The malformations with which the symptoms 
are reasonably consistent in this instance are absence of the 
ventricular septum, transposition or irregular origin of the 
great vessels and pulmonary atresia with some compensatory 
malformation. There ought not, however, to be a second 
pulmonic sound if there is pulmonary atresia, and it should 
be accentuated if there is a transposition of the vessels. It 
is idle to speculate as to the exact lesion, however, as it is 
obviously impossible to determine positively what it is. 
Fortunately a knowledge of this point is not of importance in 
relation to the treatment. 

Prognosis. He is five years old, has survived scarlet fever 
and pertussis, has developed fairly well and has no disturb- 
ance of the digestion. It seems reasonable to suppose, 
therefore, that he will live for a number of years. Any 
disease of the lungs will, however, probably prove rapidly 
fatal. If he lives, he will not be able to do any active work 
and will always have to lead a sedentary life. 

Treatment. The treatment at present consists in the 
avoidance of all exertion sufficient to cause shortness of 
breath. If evidences of failure of compensation, such as 
edema of the lungs, enlargement of the liver, ascites or 
anasarca develop, the treatment will be that of failure of 
compensation in general. 



DISEASES OF THE HEART AND PERICARDIUM. 407 

CASE 124. William C.'s father had died of tuberculosis 
just before he was born. He had had no known exposure to 
tuberculosis. He had been unusually rugged, until he was 
eight years old, when he had otitis media followed by inflam- 
mation of the mastoid and operation. A considerable amount 
of adenoids was removed at the same time. He was kept out 
of school for a year, but did not regain his strength. He was 
easily tired and not nearly as vigorous as before. An enlarge- 
ment of several of the cervical lymph nodes, which had de- 
veloped at the time of the mastoid operation, persisted until 
his tonsils were removed, when he was ten and one-half years 
old, since when they had become much smaller. He had 
chicken-pox when eleven and one-half years old and was 
considerably pulled down by it. Since then he had been 
generally below par and very easily tired. His appetite had 
been poor, but he had shown no signs of indigestion. His 
bowels had moved regularly, and the movements had been 
normal. He had had no cough. He complained a little of 
shortness of breath on exertion, but never of palpitation. 
Once, after unusual exertion, and at another time after 
getting tired, he had run a temperature between 99° F. and 
100° F. for several days. At other times his temperature had 
been normal. He had been kept very quiet during the last 
few months and not allowed to take any active exercise. He 
went to bed early and usually slept about eleven hours, but 
had no rest during the day. He had grown tall very rapidly 
during the last six months. He was of a very nervous type 
and was much worried about himself. He had no bad habits. 
He was seen when eleven and three-fourths years old. 

Physical Examination. He was tall and rather slight, but 
of fair color. His throat and mouth were healthy and his 
tongue nearly clean. There was no venous hum in the neck. 
The cardiac impulse was palpable in the fourth left space, 
7I cm. to the left of the median line. The left border of the 
relative cardiac dullness was 7J cm. to the left, and the right 
border 3 cm. to the right of the median line; the upper border 
was at the upper border of the third rib. That is, taking his 
height into consideration, the measurements to the left were 
a little small, while the others were normal. The cardiac 



408 CASE HISTORIES IN PEDIATRICS. 

action was somewhat irregular in rhythm ; the rate, 88. 
The cardiac action was steadied by exertion. The first sound 
was everywhere of fair strength. It was at times followed, 
both at the pulmonic and mitral areas, by short murmurs 
which were not transmitted. The second pulmonic sound was 
not accentuated. The lungs and abdomen were normal. 
The liver and spleen were not palpable. The extremities 
were normal. There was no spasm or paralysis. The knee- 
jerks were equal and lively. Kernig's sign was absent. 
Numerous lymph nodes, varying in size from that of a pea to 
that of a large bean, were palpable in the neck. There was 
no enlargement of the axillary and inguinal and no evidence 
of enlargement of the bronchial lymph nodes. His weight 
was eighty-nine and one-fourth pounds (average, seventy- 
six and one-half pounds). His height was fifty-nine and 
three-fourths inches (average, fifty- five). 

The urine was clear, highly acid in reaction, of a specific 
gravity of 1,038 and contained no albumin or sugar. 

Blood. 

Hemoglobin, 90% 

Red corpuscles, 4,500,000 

White corpuscles, 7,200 

Smears of the blood showed nothing abnormal in either the 
red or the white corpuscles. 

Diagnosis. The enlargement of the cervical lymph nodes 
is in all probability not tubercular, because it came on in the 
course of an acute disease, has never shown any tendency to 
suppurate and has diminished in size since the tonsils were 
removed. The fact that his father died of tuberculosis is of 
no importance, because he was not exposed to tuberculosis 
from him. There are no evidences of tuberculosis elsewhere. 
It is reasonably safe to conclude, therefore, that his poor 
condition is not due to tuberculosis. 

f The point of chief interest is the condition of the heart. 
It is certainly not an acute one. Is the trouble organic or 
functional? Anemic murmurs do not have to be considered 
because of the condition of his blood and the absence of a 
venous hum in the neck. The absence of enlargement of the 



DISEASES OF THE HEART AND PERICARDIUM. 409 

heart, taken in combination with the strong first sound and 
the absence of accentuation of the second pulmonic sound, 
show that there is no dilatation or hypertrophy of the heart, 
which would certainly be present if there was any chronic 
leakage at the mitral orifice. The presence of a murmur at 
the pulmonic orifice and the absence of transmission of the 
murmurs is also against an organic lesion. The steadying of 
the heart on exertion, the rapid growth, the nervous tempera- 
ment, the history of the previous illnesses and the fact that 
he is about the age of puberty, all point to a functional condi- 
tion. It is safe to conclude, therefore, that the Cardiac 
condition is Functional, not organic. 

Prognosis. The prognosis is perfectly good with time. It 
will probably be several years before he will be strong and 
vigorous. The irregularity of the heart and the murmurs will 
probably disappear much sooner. 

Treatment. The treatment must be by regulation of his 
daily life, not by drugs. In the first place, he must be assured 
that there is nothing serious the matter with him, that his 
weakness is merely the result of his illness and his rapid growth 
and that he will surely be all right again. He must not go to 
school more than half a day. If he does not go at all, he will 
have too much time to think about himself. He must be 
amused in quiet ways. He must partly undress and lie down 
for an hour at noon and rest, even if he does not sleep. He 
must be in bed at eight. It will be a good thing for him to 
sleep out of doors. He can walk, drive, ride in an automobile, 
play golf and work a little about the house, but must not 
play baseball or football, ride a bicycle or skate. He may 
have any reasonable food. He should have three good meals 
and a lunch in the morning. Care must be taken that his 
bowels move regularly. Tincture of nux vomica, in eight- 
drop doses, three times daily, before meals, will probably 
improve his appetite and his general condition. 



410 CASE HISTORIES IN PEDIATRICS. 

CASE 125. Samuel C, four and one-half years old, had 
been perfectly well since an attack of acute nephritis two 
years before. About two weeks before he was seen he began 
to complain of pain and stiffness in the ankles, wrists and 
elbows. He apparently did not feel sick and was not feverish. 
He had been allowed to be out of doors as usual, although it 
was winter. He had had no treatment. The day he was seen 
he had not seemed quite as well, although nothing very definite 
had appeared. He was seen in the evening. 

Physical Examination. He was well developed and nour- 
ished and of good color. He did not seem sick. He com- 
plained of slight pain when his ankles, wrists and elbows were 
moved. The right wrist was tender on pressure; the other 
joints were not. There was no redness, heat or swelling about 
any of them. The cardiac impulse was visible and palpable 
in the fifth space, 8 cm. to the left of the median line (the 
normal is in the fourth space, 6 to 6J cm. to the left of the 
median line). The upper border of the relative cardiac 
dullness was at the lower border of the second rib (normal 
is in second space), the right border 2 J cm. to the right of the 
median line (normal), and the left border 8 cm. to the left of 
the median line (normal is 6 to 6| cm.). The cardiac action 
was somewhat irregular; the rate was 104 (normal is 90 to 
100). The first sound at the apex was strong, but continued 
into a short, blowing murmur, transmitted into the axilla. 
The second sound at the apex was reduplicated. The second 
sound at the pulmonic area was accentuated. The lungs and 
abdomen were normal. The liver and spleen were normal. 
There was no spasm or paralysis. The knee-jerks were equal 
and normal. There was no enlargement of the peripheral 
lymph nodes. There was no venous hum in the neck. The 
mouth temperature was 102° F. 

Diagnosis. The history and the conditions found in the 
joints are typical of Rheumatism in childhood, at which age 
marked joint and constitutional symptoms are very un- 
common. The disease is, therefore, very often overlooked, 
as it was in this instance. Unfortunately the heart is involved 
even more frequently in this mild type of rheumatism in 
childhood than it is in the severe type in adult life. 



DISEASES OF THE HEART AND PERICARDIUM. 4I I 

There Is undoubtedly something abnormal about the heart. 
The possibilities are acute endocarditis, myocarditis and an 
anemic murmur. The latter can be at once excluded on the 
good color, the absence of a venous hum in the neck and the 
enlargement of the heart. The absence of a murmur at the 
pulmonic area is also against it. Myocarditis can be ruled out 
on the character of the impulse, the strength of the first sound 
and the accentuation of the second sound in the pulmonic 
area. The absence of enlargement to the right and of much 
increase in the rate of the pulse is also against it. The diag- 
nosis is, therefore, by elimination, Acute Endocarditis of 
the mitral valve. The combination of a systolic murmur at 
the apex with a strong impulse, strong first sound, but little 
increase in the rate of the heart, enlargement limited to the 
left side and an accentuation of the second pulmonic sound, is, 
moreover, characteristic of an early endocarditis of the mitral 
valve. 

Prognosis. There is no immediate danger to life from the 
endocarditis, the chief immediate danger being the simul- 
taneous involvement of the myocardium and pericardium. 
When all parts of the heart are involved, the prognosis is 
always a grave one. There is, however, very little chance of 
complete recovery. The disease is almost certain to result 
in permanent deformity of the mitral orifice. There is, more- 
over, great danger of recurrence of the rheumatism in the 
future with further damage to the endocardium. It must be 
remembered in this connection that the murmurs due to 
acute endocarditis frequently disappear, to be followed later 
by those due to cicatricial changes in the orifices. The dis- 
appearance of the murmur does not, therefore, justify a 
favorable prognosis. This can only be given when the mur- 
mur has not reappeared after an interval of one or two years. 

Treatment. The author is one of those who believe that 
the salicylates do good in rheumatism. It seems reasonable 
that, if they help rheumatism, they will have a favorable 
influence upon the endocarditis, which is a manifestation of 
rheumatism. It is hard to understand, at any rate, how they 
can do any harm in rheumatism, as some wTiters claim they 
do. The most satisfactory preparation of salicylic acid for 



412 CASE HISTORIES IN PEDIATRICS. 

children is aspirin. This boy should have five grains every 
three hours until the joint symptoms and fever are relieved, 
unless he gets toxic symptoms. If he does, the dose should be 
reduced. It should be continued in the same dose, three 
times a day, for several days or a week longer. 

The most important thing in the treatment of acute endo- 
carditis in childhood is rest. Everything else is subordinate. 
He must be kept in bed not only during the acute stage, but 
for months longer. Three months is the minimum. A week 
in bed at this time may mean a year of life later. In the 
beginning he must be kept flat or as nearly flat as is possible. 
Judgment must be used in this connection, however, because 
he may fret and fuss so much at being kept flat that he will 
bring more strain on his heart than if he is allowed to sit up. 
His life must be most carefully regulated for a year or two 
after he gets up, and the amount of exertion limited. He will 
feel perfectly well and will w4sh to do what other children do. 
He must, however, be restrained. His whole life must be 
planned so as to save the heart. 

His compensation is perfectly good. There is, therefore, 
no call for either cardiac stimulants or tonics. If he is restless 
or uncomfortable, he may be given the bromide of sodium or 
potassium in five- or ten-grain doses, or morphia in doses of 
from one thirty-second to one sixteenth of a grain. 

There are no special indications as to his diet. He must be 
given a milk and starchy diet at first. Later, there is no 
objection to meat and eggs. Special attention must be paid 
to his nutrition, as the condition of the heart muscle depends 
to a considerable extent on the general nutrition. 



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Chart of Case 126. 



DISEASES OF THE HEART AND PERICARDIUM. 4I3 

CASE 126. Carl J., eleven years old, had three brothers 
living and well. His parents and a sister had died of acute 
diseases. He had measles and whooping-cough when nine 
years old and had been circumcised two months before the 
onset of his illness. The heart was examined at that time, 
but nothing abnormal was detected. He was taken sud- 
denly sick July 26 with vomiting, fever and headache. The 
vomiting and headache ceased after twenty-four hours, but 
the fever continued. He did not complain of sore throat, 
but the physician who saw him on July 28 found the throat 
reddened, the tonsils large and the fauces and pharynx cov- 
ered with purulent material. The heart was not enlarged 
at that time, but a loud systolic murmur was heard all over 
the precordia and in the axilla. The rest of the physical 
examination was negative. The throat cleared up rapidly 
and no new physical signs developed. The fever continued, 
however, as is shown by the accompanying chart. He had 
a chill on August 6 and on August 8 two chills, with two 
marked exacerbations of temperature. He took his food 
fairly well and had no disturbance of the digestion, but 
lost weight and strength very rapidly. He was troubled by 
headache, mostly occipital, after August i, and complained 
constantly of pain in the legs. This was not helped by 
aspirin, and Roentgenographs showed no disease of the 
bones or joints. The urine, which was examined July 29, 
was clear, acid in reaction and contained no albumin or 
sugar. The sediment showed a few leucocytes and large 
round cells, but no casts. A skin tuberculin test on July 21 
was negative. Widal tests on July 31 and August 9 were 
negative. Blood cultures on July 31 and August 6 were also 
negative. The leucocyte count, July 29, was 5600, with 
60% of polynuclear cells. It was 12,400, with 85% of polynu- 
clears, on August 6, and on August 9, 12,000 with 80% of 
polynuclears. No plasmodia malariae were found at three 
examinations. He was seen in consultation, August 9. 

Physical Examination. He had evidently lost much flesh. 
He was perfectly clear mentally. There was no rigidity of 
the neck or neck sign. The pupils were equal and reacted to 
light. The tongue was considerably coated. The throat 



414 CASE HISTORIES IN PEDIATRICS. 

was normal. The cardiac impulse was in the fifth space, 
seven and one-half cm. from the median line. The left 
border of dullness was one-half cm. farther out, the right 
border three and one-half cm. to the right of the median 
line, the upper border at the upper border of the third rib. 
The action was regular. The first sound at the mitral area 
and apex was replaced by a loud, blowing murmur, trans- 
mitted into the axilla. The first sound was audible at the 
base of the heart, as was the murmur. The second sound at 
the pulmonic area was accentuated. There was no venous 
hum in the neck. The lungs were normal and there was no 
evidence of enlargement of the tracheo-bronchial lymph nodes. 
The liver was not palpable. The upper border of the splenic 
dullness v/as at the ninth rib. The spleen was not palpable. 
The abdomen was level, soft and tympanitic. There were 
no rose spots. The extremities were normal. There was 
no spasm or paralysis. The knee-jerks were equal and nor- 
mal. There was no Kernig's sign. He was generally hyper- 
esthetic, especially in the legs. The inguinal and axillary 
lymph nodes were palpable and seemed tender. The rectal 
temperature was 105.2° F. ; the pulse, 124; the respiration, 30. 
Diagnosis. The diseases to be considered in this instance 
are typhoid fever, malaria, acute miliary tuberculosis, rheu- 
matism with endocarditis and malignant endocarditis. The 
temperature and pulse rate, while not characteristic of 
typhoid fever, are not inconsistent with it. The increase in 
the number of white cells is so slight that it does not count 
against it. Typhoid fever can be positively excluded, how- 
ever, on the negative blood culture on the sixth day, the 
negative Widal test on the fifteenth day of the disease, the 
absence of rose spots and enlargement of the spleen at two 
weeks, and the relative increase of the polynuclear leuco- 
cytes. The onset was quicker, moreover, than is usual in 
typhoid at this age. Malaria is suggested by the irregu- 
larity of the temperature, the chills and the absence of a 
marked leucocytosis. It can be ruled out on the absence 
of enlargement of the spleen, the failure to find plasmodia on 
three occasions and the relative increase of the polynuclear 
leucoc3^tes. The irregular temperature and the rapid loss 
of weight and strength are suggestive of the typhoidal type 



DISEASES OF THE HEART AND PERICARDIUM. 415 

of acute miliary tuberculosis, as is the absence of marked 
leucocytosis. The negative tuberculin test does not count 
against it, because it is ver}^ often negative in this type of 
tuberculosis. There are, however, no physical signs of any 
primary focus and the pulse is slower than is usual in this 
disease. It would be hard to exclude it, however, if the 
signs in the heart did not point so strongly to trouble there. 
The presence of these signs is, moreover, strong negative evi- 
dence against typhoid fever and malaria. Rheumatism with 
endocarditis is suggested by the pains in the extremities and 
the signs of a cardiac lesion. The pains are general and indefi- 
nite, however, there are no evidences of involvement of the 
joints and aspirin has not relieved them. The general con- 
dition is much worse than would be expected if this was the 
trouble, when it is taken into consideration that the heart 
is but little enlarged. It seems as if there must be some- 
thing more serious than this the matter with him. The 
high, irregular temperature, the chills and the rapid loss of 
weight and strength show that there is a septic infection of 
some sort. The absence of all evidences of infection, except 
in the heart, proves that this must be the seat of the infec- 
tion. The diagnosis of malignant endocarditis seems, there- 
fore, a reasonable one. The relative increase in the number 
of polynuclear leucocytes is also in favor of this diagnosis. 
The reason that the leucocytosis is not larger, as it would 
be expected to be, is probably because the system is over- 
whelmed by the infection. It is harder to explain the nega- 
tive blood cultures. All that can be said is that, while blood 
cultures are usually positive in malignant endocarditis, they 
are not always so. The negative blood cultures do not seem 
sufficient, therefore, to in any way counterbalance the evi- 
dence in favor of Malignant Endocarditis, which is the 
only diagnosis consistent with the symptoms and which is 
undoubtedly the correct one. The infection presumably came 
from the throat. 

Prognosis. The prognosis is absolutely hopeless. He will 
probably not live more than a week or ten days, but may 
linger on for several weeks. 

Treatment. There is no curative treatment. All that can 
be done is to make him as comfortable as possible. 



41 6 CASE HISTORIES IN PEDIATRICS. 

CASE 127. Philip N. was admitted to the Children's 
Hospital, October 10, when seven and one-half years old. 
His parents and five other children were alive and well. 
Five had died of various diseases. There had been no mis- 
carriages. He had had no known exposure to tuberculosis. 
He had always been well, except for measles and whooping- 
cough in infancy, until he had rheumatism a year before. 
This was complicated by acute endocarditis and chorea. He 
was in bed for eleven weeks, after which he made a slow but 
good recovery. He had played about with the other boys 
all summer and had had no shortness of breath or palpitation. 

He was taken suddenly sick October 3 with headache, fever 
and dyspnea. Pain, redness and swelling appeared in the 
right knee the next day and since then the other knee, the 
right ankle and both wrists had been affected. He had also 
had some pain in the precordia, which at times ran up into 
the left shoulder. He had taken his food well, had not 
vomited and had had regular movements of the bowels. 

Physical Examination. He was well developed and nour- 
ished and moderately pale. There was a tinge of cyanosis 
in the cheeks, about the mouth and in the hands and feet. 
His expression was anxious and he was unable to lie down 
with comfort. The tongue was covered with a moist, white 
coat. The throat was normal. The cardiac impulse was 
heaving. It was seen and felt most distinctly in the fifth 
space, ten and one-half cm. to the left of the median line. 
The left border of the cardiac dullness was eleven cm. to the 
left of the median line (normal is seven cm.) and the right 
border four and one-half cm. to the right of the median line 
(normal is two and one-half cm.). The cardio-hepatic angle 
was acute. The upper border of the cardiac dullness was in 
the second space (normal is under third rib). The action 
was regular, the rate 140. The first sound at the apex was 
somewhat feeble and was followed by a loud, blowing mur- 
mur, which was transmitted into the axilla and back. Both 
sounds were feeble in the aortic area. The second sound in 
this area was followed by a short, harsh murmur, which was 
heard much more distinctly in the third left space and which 
could be followed down to the apex, where it became inaudible. 



DISEASES OF THE HEART AND PERICARDIUM. 417 

The second sound in the pulmonic area was louder than that 
in the aortic area. There was a Corrigan pulse, a capillary 
pulse and a pistol-shot sound in the groin. The lungs were 
normal, except for a few fine, moist rales at the bases behind. 
The upper border of the liver flatness in the nipple line was 
at the upper border of the fifth rib; the lower border was 
palpable three cm. below the costal border in the same line. 
The spleen was just palpable. The abdomen was slightly 
distended, but otherwise normal. The extremities showed 
nothing abnormal, except slight clubbing of the fingers and 
toes. There was no tenderness or edema. The knee-jerks 
were equal and lively. There was no enlargement of the 
peripheral lymph nodes. The rectal temperature was 99.2^ 
F. ; the pulse, 140; the respiration, 44. 

The urine was of normal color, acid in reaction, of a specific 
gravity of 1023, and contained no albumin, sugar or bile. 

The white corpuscles numbered 15,600. 

Diagnosis. He undoubtedly has Chronic Valvular 
Disease of the Heart. If the marked enlargement of the 
heart was due to an acute disease of the heart, whether 
endocarditis, myocarditis or a combination of the two, occur- 
ring in association with the Rheumatism during the last 
week, the impulse would not be heaving, the murmurs would 
not be so loud and the signs of failure of compensation would 
be very marked. The systolic murmur at the apex is indica- 
tive of mitral insufliiciency. The characteristics of the dia- 
stolic murmur are those of the murmur of aortic insufficiency. 
This diagnosis is confirmed by the Corrigan pulse, the capil- 
lary pulse and the pistol-shot sound in the groins. The 
increase in the rate of the pulse and respiration are out of 
proportion to the increase in the temperature and greater 
than would be expected in chronic valvular disease as well 
compensated as it seems to be in this instance. This excessive 
increase in the rate of the pulse and respiration, together with 
the slight tinge of cyanosis, the anxious expression, the 
tendency to orthopoea and the precordial pain, show that 
there is some acute cardiac lesion in addition to the chronic 
valvular disease. The absence of a friction rub and of the 
signs of effusion into the pericardium shows that the peri- 



41 8 CASE HISTORIES IN PEDIATRICS. 

cardium is not involved. It is probable that, as is usual in 
such cases, both the endocardium and myocardium are 
affected. The relatively strong first sound shows, however, 
that the myocardium is not severely involved. A probable 
diagnosis of Acute Endocarditis seems, therefore, justifi- 
able. The fine rMes in the back and the enlargement of the 
liver and spleen are undoubtedly the result of the disease 
of the heart. 

Prognosis. The rheumatism will yield quickly to treat- 
ment and the acute endocarditis will, in all probability, quiet 
down. He will be left, however, with a heart more damaged 
than it was before. This damage is so great that, although 
it is probable that compensation will soon be reestablished, 
it is only a question of time when it will break down again. 
It may be reestablished several times, but it will sooner or 
later give out once for all. He will almost certainly die of 
cardiac failure within a few years. 

Treatment. The treatment of rheumatism and acute 
endocarditis, as well as inferentially of chronic valvular 
disease, is discussed elsewhere (see Case 125). He should be 
given five grains of aspirin every three hours for the present. 
He should be kept as quiet as possible in bed and bolstered 
up enough so that he can breathe freely. His diet should 
consist of milk prepared in various ways, starches, ice cream 
and custard. He should be given five or six small feedings 
during the twenty-four hours. Water should not be pushed, 
as large amounts increase the strain on the circulation. If 
he is restless and uncomfortable, he should be given bromide 
of soda in 15 grain doses. If this does not quiet him, it will 
be wise to give him morphia in doses of from 2T to iV of a 
grain. While digitalis is not indicated in acute endocarditis 
and myocarditis, it Is useful when there is failure of compen- 
sation in the course of chronic valvular disease, as in this 
instance. He should be given five minims of the tincture of 
digitalis every six hours ; more if necessary. 



DISEASES OF THE HEART AND PERICARDIUM. 



419 



CASE 128. Ernest M., nine years old, was admitted to the 
Children's Hospital January 5, on the sixth day of a pneu- 
monia of the left lower lobe. He was in good condition and the 
physical examination showed nothing else abnormal. The 



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Ernest M. Case 128. 



cardiac impulse was visible and palpable in the fifth space, 
7 cm. to the left of the median line and just inside the nipple 
line. The upper border of the relative cardiac dullness was 
at the upper border of the third rib; the left border corre- 



420 CASE HISTORIES IN PEDIATRICS. 

sponded to the impulse and the right border was 2 J cm. to the 
right of the median line (all normal). The action was regular. 
The first sound was of fair quality. The second sounds were 
alike. There were no murmurs. 

The crisis, as will be seen by the chart, occupied two days. 
The temperature reached normal the afternoon of January 7. 
The pulse remained good during the crisis. The temperature 
remained down and the lung began to clear at once, but the 
pulse became infrequent and irregular the night of the 8th. 
The examination the next morning, January 9, was as follows: 

Physical Examination. He was perfectly comfortable and 
of good color. The cardiac impulse was wavy and visible in 
several spaces. It was most distinctly palpable in the fifth 
space, 8| cm. to the left of the median line. The upper 
border of the relative cardiac dullness was in the second space, 
the left border was just outside the point of maximum im- 
pulse and the right was 4 cm. to the right of the median line. 
The action was irregular in both force and rhythm; the rate 
was 68 (normal is 80 to 90). All the beats were transmitted 
to the wrist. The first sound was everywhere short and some- 
what feeble. The second sounds were alike. There were no 
murmurs. There was still a little dullness and a few moist 
rales over the left lower lobe. The physical examination 
showed nothing else abnormal. 

Diagnosis. The physical signs are those of weakness and 
dilatation of the heart. The weakness and dilatation cannot 
be the results of an endocarditis, because the heart was 
normal four days before and no leakage which did not show 
then could possibly have caused so much dilatation and weak- 
ness in four days. There is no cause outside of the heart to 
account for its sudden failure. The cause of the dilatation and 
weakness must, therefore, be in the heart wall. That is, there 
is a Myocarditis. The diminution of the second sound at 
the pulmonic area at entrance (the second pulmonic sound is 
normally louder than the second aortic at this age) showed 
that the right ventricle was unable to meet the increased 
resistance in the pulmonary circulation and gave warning of 
what happened later. 

Prognosis. The prognosis is a grave one. A marked 



DISEASES OF THE HEART AND PERICARDIUM. 42 1 

diminution in the pulse-rate in myocarditis is as serious, if 
not more so, than a marked increase in the rate. He may die 
at any time; he may slowly improve and finally recover 
entirely. It is impossible to forecast what will happen. The 
outlook depends to a considerable extent on the treatment. 

Treatment. The most important part of his treatment is 
quiet. He must be kept perfectly flat and not allowed to sit 
up for any reason whatever. He must be kept flat, or nearly 
flat, until the cardiac action and rate are normal and all signs 
of dilatation and weakness have disappeared. He may then 
begin to gradually get up and about. Alcohol is useless in 
myocarditis, except as a food. In large doses it undoubtedly 
does harm. Strychnia may possibly help some. Digitalis 
cannot act on a degenerated muscle. Nitroglycerin is danger- 
ous because it predisposes to vasomotor paralysis. There is, 
therefore, no drug treatment indicated at present. He may 
have liquids in moderate amounts, soft solids and eggs. It 
will be wiser to give him small meals five or six times in the 
twenty-four hours than large ones at longer intervals. 



422 CASE HISTORIES IN PEDIATRICS. 

CASE 129. Mary M., seven years old, had had measles, 
whooping-cough and rheumatism in the past. She com- 
plained of *'pain in her stomach" January 3, and two days 
later began to have pain in the knees and could not use her 
legs. The pain left her knees January 7 and she began to 
complain of precordial pain and shortness of breath. Twitch- 
ing of the face and extremities began January 9. She had, 
nevertheless, taken food fairly well and had had no disturb- 
ance of the digestion. She was admitted to the Children's 
Hospital, January 13, and was seen soon after. 

Physical Examination. She was fairly developed and 
nourished, but very pale. There was moderate cyanosis of 
the lips and cheeks. She was bolstered up on pillows, was 
gasping for breath and took almost no notice of what was 
going on about her. The cardiac impulse was just palpable 
in the fifth left space, a little outside the nipple line. The 
left border of the cardiac dullness was in the midaxillary line, 
the upper border at the upper border of the second rib and 
at the middle of the manubrium, whence the right border ran 
diagonally downward and outward, reaching the upper border 
of the liver flatness at the sixth rib, just inside the right nipple 
line. The cardiac action was regular, but the sounds were 
very feeble. The second pulmonic was louder than the 
second aortic sound. No murmurs were heard and there 
was no friction rub. There was marked dullness, with 
bronchial respiration, in the left back below the level of the 
middle of the scapula between the median and scapular lines. 
There were many fine, moist rales throughout both backs. 
The lower border of the liver was palpable at about the level 
of the navel in the nipple line. The liver was tender. The 
spleen was not palpable. There was no edema of the face 
or extremities. There were occasional involuntary twitch- 
ings of the face and extremities. No further examination 
was made, because of her critical condition. The mouth 
temperature was 101.2° F.; the pulse, 132; the respiration, 

40. 

Diagnosis. The position of the impulse, well inside the 
left border of the cardiac dullness, the obtuse cardio-hepatic 
angle and the relatively slight increase in the rate of the heart, 



DISEASES OF THE HEART AND PERICARDIUM. 423 

together with the feebleness of the heart sounds while the 
second pulmonic is louder than the second aortic sound, are 
so different from the physical signs found in dilatation of the 
heart with failure of compensation, the only condition with 
which it could be confused, that an absolute diagnosis of 
Pericarditis with Effusion is justified. The area of 
dullness and bronchial respiration in the left back is pre- 
sumably the result of compression of the lung and is corrobo- 
rative evidence in favor of a pericardial effusion. The fine 
rales in the backs are indicative of edema of the lungs from 
interference with the pulmonary circulation. The enlarge- 
ment and tenderness of the liver are undoubtedly due to 
trouble in the heart, but suggest that there is some other 
lesion in addition to the pericarditis. The history of rheu- 
matism in the past and the loud second pulmonic sound 
suggest that there is also some valvular lesion. It is im- 
possible to determine at present, however, whether this is 
the case or not. She has, of course, Rheumatism and 
Chorea as well as pericarditis. The pericarditis having 
developed in the course of rheumatism and chorea, the effu- 
sion is almost certainly serous in character. 

Prognosis. She will die within a few hours, if the fluid is 
not removed at once from the pericardium. It is impossible 
to say whether it will reaccumulate after its removal, but the 
chances are that it will not. No more definite prognosis can 
be given until the condition of the myocardium and endo- 
cardium is determined after the withdrawal of the fluid. If 
she recovers, she will probably be left with an adherent peri- 
cardium, which may or may not cause trouble in the future. 

Treatment. The pericardium must be emptied at once. 
The fifth right interspace is, as a rule, the best place to tap it. 
The trocar should be introduced in this instance about two 
cm. inside of the right nipple line, which will be far enough 
out to avoid the internal mammary artery. As much fluid 
as possible should be withdrawn. It is probable that eight 
or ten ounces will be obtained. A light icebag should then 
be suspended over the precordia in such a way that it will not 
cause pressure. It will probably make her more comfortable 
and may, perhaps, hinder the reaccumulation of the fluid. It 



424 CASE HISTORIES IN PEDIATRICS. 

will be well also to give her three drops of the tincture of 
digitalis every four hours for the present. If disease of the 
endocardium is discovered after the withdrawal of the fluid, 
it may be necessary to give her larger doses. The treatment 
of pericarditis is given in more detail in Case 130. 



DISEASES OF THE HEART AND PERICARDIUM. 425 

CASE 130. Levi P., fifteen years old, had had repeated 
attacks of rheumatic fever since he was four years old. He 
began to be short of breath on exertion when he was fourteen, 
but this was never severe enough to cause any inconvenience. 
He occasionally suffered from palpitation. He had another 
attack of rheumatic fever the latter part of May. Since then 
dyspnea and palpitation had been very troublesome and any 
exertion completely exhausted him. His appetite was good 
and his bowels moved regularly. He had no signs of indiges- 
tion. He had a slight cough, but no expectoration. The 
dyspnea and palpitation finally became so troublesome that 
he gave up and went to bed June i6. He was able to lie 
down, but was more comfortable sitting up. Rest in bed 
made him more comfortable until June 20, when he began to 
complain of pain and oppression in the chest. He became 
rapidly worse, so that on the 226. he was unable to lie down 
with comfort, was restless and had begun to vomit. The 
temperature, which had been running between normal and 
101° F., gradually went up to 102° F., and the rate of the 
pulse and respiration rose from 100 and 25 to 140 and 40, 
respectively. He was seen in consultation June 22. 

Physical Examination. He was well developed and nour- 
ished. He was restless and unable to lie down. His expres- 
sion was anxious. He was everywhere slightly cyanotic. 
The cardiac impulse was not visible; it was palpable in the 
fourth space, midway between the sternum and the nipple 
(normal is fifth space, i cm. inside the nipple). The upper 
border of the relative cardiac dullness was at the upper border 
of the second rib (normal is middle of third rib) ; the left 
border 13 cm. (normal is 8 or 9 cm.) to the left of the median 
line; the right border 6 cm. (normal is 3 to 4 cm.) to the right 
of the median line in the fourth space, and 7 cm. to the right 
of the median line in the fifth space. The action was regular ; 
the rate, 140. The heart sounds were markedly feeble. The 
first sound at the apex was preceded by a faint, rumbling sound 
and directly followed by a soft, blowing sound which was 
transmitted toward the axilla. The second pulmonic sound 
was somewhat louder than the second aortic. There was a 
soft, double, rubbing sound close to the ear and increased by 



426 CASE HISTORIES IN PEDIATRICS. 

pressure of the stethoscope, synchronous with the heart beat, 
under the manubrium and in the second spaces. The pulse 
was fairly strong. There w^as an area of dullness, with bron- 
chovesicular respiration and slightly increased voice sounds, 
at the base of the left lung, extending outward about 7 cm. 
from the median line and upward about 5 cm. There were 
numerous very fine, moist rales in both lower backs. The 
lungs were otherwise normal. The upper border of the liver 
flatness was at the upper border of the sixth rib in the nipple 
line ; the lower border was not palpable. The spleen was not 
palpable. The abdomen was normal. The extremities showed 
nothing abnormal. There was no spasm or paralysis and no 
edema. 

The urine was high, acid in reaction, of a specific gravity of 
1,024 and contained neither albumin nor sugar. The sedi- 
ment showed nothing abnormal. 

Diagnosis. The trouble is, of course, entirely cardiac. 
The condition in the heart is, however, a fairly complicated 
one. The location of the impulse well inside the left border 
of the cardiac dullness, the combination of feeble heart sounds 
with a regular action, a reasonably strong pulse, and an accen- 
tuated second pulmonic sound, and the extension of the 
right border of dullness farther to the right in the fifth than 
in the fourth space (thus making the cardio-hepatic angle 
obtuse) prove that there is a Pericardial Effusion. The 
peculiar characteristics of the double rubbing sound under 
the manubrium and in the second spaces show that there is 
also a Dry Pericarditis at the base. This is corroborative 
evidence of pericardial effusion. The presence of cyanosis 
and distress without edema and enlargement of the liver and 
spleen also counts in favor of a pericardial effusion and against 
a dilatation of the heart. The effusion developed immedi- 
ately after an attack of rheumatism, and is, therefore, almost 
certainly serous. The absence of marked irregularity in the 
temperature and of chills and sweating is also in favor of a 
serous fluid. 

The double murmur at the apex shows that there is a lesion 
at the Mitral orifice, certainly Insufficiency, probably 
Stenosis, perhaps only roughening of the orifice. The 



DISEASES OF THE HEART AND PERICARDIUM. 4^7 

effusion into the pericardium makes it impossible to determine 
the size of the heart. The accentuation of the second pul- 
monic sound shows, however, that there must be hypertrophy 
of the heart and that, if there are both dilatation and hyper- 
trophy, the hypertrophy is in the ascendance. The history of 
repeated attacks of rheumatism and of dyspnea and palpita- 
tion before the present illness shows that the lesion is a chronic 
one. The accentuation of the second pulmonic sound is 
corroborative evidence. The strength of the pulse, the good 
second sound and the regularity of the heart show that the 
myocardium is but little, if at all, affected. 

The area of dullness and bronchovesicular respiration in 
the lower left back is due to compression of the lung by the 
pericardial effusion. The rales show a small amount of edema 
of the lungs. 

Prognosis. The prognosis in this instance, as always in 
pericarditis with effusion, especially if associated with chronic 
valvular lesions, is a very grave one. The most favorable 
point here is the absence of myocardial involvement. There 
is a reasonable chance, perhaps one in four, that he will sur- 
vive the present acute condition. He will be left, however, 
not only with a chronic valvular lesion, but also with an ad- 
herent pericardium. He is also very liable to have more 
attacks of rheumatism and further involvement of the heart. 
If he survives the present attack, the chances are, therefore, 
that he will live but a few years. 

Treatment. The first thing to be decided is whether it is 
advisable to tap the pericardium. The heart is standing up 
to the increased work very well, as is shown by the regularity 
of its action, the good pulse and the accentuation of the second 
pulmonic sound; there is almost no edema of the lungs and 
no signs of passive congestion elsewhere. If he can be kept 
under close observation, it will be wise to delay aspiration in 
the hope that the effusion will diminish rather than increase. 
If the heart weakens or signs of passive congestion appear, the 
pericardium must be tapped at once. Blisters and the appli- 
cation of other counterirritants to the precordia can do no 
good, will make him uncomfortable and increase the chances 
of septic infection. A light ice-bag, suspended over the pre- 



428 CASE HISTORIES IN PEDIATRICS. 

cordia so as not to cause pressure, may make him more com- 
fortable and in some instances seems to favor the absorption 
of the fluid. Tincture of digitalis, in doses of five drops every 
four hours, will help the heart to meet the increased work 
thrown on it by the pressure of the fluid in the pericardium. 
This dose may be doubled or trebled, if necessary. He may 
sit up or lie down, according to which is the more comfortable. 
Fresh air will make his breathing easier. Oxygen may be 
given, if necessary. There is no objection to morphine, in 
doses of from one sixteenth to one eighth of a grain, if he is 
very uncomfortable. 

He must be fed often with small amounts of liquids and soft 
solids, since swallowing is often very painful and chewing 
tiresome. 



DISEASES OF THE HEART AND PERICARDIUM. 429 

CASE 131. Clarence G., eleven years old, was the child of 
healthy parents. There was nothing in the family history to 
suggest syphilis. There was no tuberculosis in the family and 
he had had no known exposure to it. He was born at full 
term after a normal labor and was normal at birth. He was 
breast-fed and w^as very well as a baby. He had measles and 
whooping-cough when five, diphtheria when six, scarlet fever 
when seven, and chicken-pox when nine years old. H^e had a 
short indefinite illness, associated with pains in the extremi- 
ties, in January, 1907, which was called " grippe." His ab- 
domen began to swell about the first of April, 1907. Some 
months later he began to be short of breath and to have a 
little swelling of the legs. The swelling of the abdomen and 
the dyspnea did not change much, but the swelling of the 
extremities often disappeared entirely for a time. His appe- 
tite and digestion continued good. Recently he had been 
unable to lie down with comfort, had had some cough and 
more swelling of the legs. He had had no fever. He was seen 
September 9, 1908. 

Physical Examination. He was well developed and nour- 
ished and of good color, but unable to lie down without much 
discomfort. There was no edema of the face or chest, and no 
enlargement of the superficial veins of the chest. There was 
no tracheal tug and no diastolic collapse of the veins in the 
neck. The tongue was clean, the throat normal. There was 
no dullness under the manubrium. The cardiac impulse was 
not visible and was only feebly palpable in the region of the 
nipple. There was no systolic retraction either here or in the 
back. The upper border of the relative cardiac dullness was 
at the upper border of the third rib; the left, just outside the 
left nipple (normal is i cm. inside); the right, 5 cm. to 
the right of the median line (normal is 3 cm. to the right of 
the median line). The cardio-hepatic angle was acute. The 
action was regular. The first sound was a little short and 
sounded a little distant. The second pulmonic sound was not 
accentuated. There were no murmurs. There was dullness, 
changing to flatness toward the base, on the left side below 
the spine of the scapula behind, the fifth rib in the axilla and 
the third rib in front. The respiration and voice sounds in 



430 CASE HISTORIES IN PEDIATRICS. 

this area were somewhat diminished in intensity, but not 
changed in character. The vocal fremitus was somewhat 
diminished. A few rales were heard. There was dullness over 
the whole right back with a few fine, moist r^les at the base. 
The abdomen was much and symmetrically enlarged. There 
was no enlargement of the superficial veins. There was 
flatness in the flanks and hypogastrium, the upper border of 
the flatness being concave when he lay on his back. The 
area of flatness changed with change of position and there 
was a definite fluid wave. No masses were felt. The upper 
border of the liver flatness was at the upper border of the 
fifth rib in the nipple line (normal is at the upper border of 
the sixth rib) ; the lower border of the liver was palpable 
II cm. below the costal border in the nipple line (not nor- 
mally palpable). The spleen was not palpable. There was 
some edema of the external genitals and legs. The pulse was 
stronger in the left than in the right wrist, and was of the 
paradoxical type. There was no enlargement of the peripheral 
lymph nodes. 

The urine was normal in color, acid in reaction and of a 
specific gravity of 1,025. It showed a very slight trace of 
albumin, but did not contain sugar. The sediment showed an 
occasional hyaline and fine granular cast, a few free leucocytes 
and many squamous cells. 

Blood. 



Hemoglobin, 


80% 


Red corpuscles, 


5,600,000 


White corpuscles, 


6,700 


Mononuclears, 


22% 


Poly nuclear neutrophiles, 


76% 


Eosinophiles, 


1% 


Myelocytes, 


1% 



There was no variation in the size or shape of the red cells 
and no stippling. 

A skin tuberculin test was negative. 

Diagnosis. The most reasonable explanation of this boy's 
condition is as follows: The illness which was called " grippe " 
was in all probability rheumatism. He developed a low-grade 
pericarditis and mediastinitis which resulted in the oblitera- 



DISEASES OF THE HEART AND PERICARDIUM. 43 1 

tion of the pericardial cavity and the formation of adhesions 
between the pericardium and the mediastinal tissues. The 
negative tuberculin test shows that this process was not 
tubercular, as it sometimes is. The points in favor of this 
assumption are the feeble cardiac impulse and the enlarge- 
ment of the area of dullness in connection with normal heart 
sounds, the paradoxical pulse and the difference in the strength 
of the pulse in the two wrists. Many other signs, sometimes 
present in this condition, are, it is true, lacking, but these 
seem sufificient to justify the diagnosis. 

The inflammatory process extended to the pleurae and 
resulted in the formation of pleural adhesions and thickening, 
which account for the signs in the backs. The pleural adhe- 
sions interfere with expansion of the lungs, as does the pressure 
of the distended abdomen and of the enlarged liver, and cause 
a congestion at the bases, which accounts for the rales. 

The chronic adhesive pericarditis produced a cirrhosis of 
the liver. This type of cirrhosis is a peculiar one and due only 
in part to passive congestion. It is not accompanied by the 
signs of congestion in other organs. The first symptom of 
this condition which is usually noticed is, as in this instance, 
enlargement of the abdomen as the result of ascites. The 
edema of the external genitals and legs is due to the pressure 
of the fluid in the abdomen on the inferior vena cava, not to 
passive congestion. The changes in the urine are presumably 
largely due to passive congestion of the kidneys from the 
pressure of the ascitic fluid on the renal veins and cava. 
The final diagnosis is, therefore. Chronic Adhesive Peri- 
carditis, with sequelae. 

Prognosis. There is, of course, no cure for the lesions in 
the pericardium, mediastinum, pleurae and liver. He will 
probably live, however, for a number of years. 

Treatment. Tapping the abdomen from time to time will 
make him much more comfortable. Other treatment must 
be symptomatic. 



SECTION IX. 
DISEASES OF THE LIVER. 

CASE 132. Richard B. was weaned suddenly July i, when 
about nine months old, because his mother was found to be 
pregnant. He was very large at birth and had gained weight 
very rapidly. He was not as active, either physically or 
mentally, as most babies of his age. He was given a very 
improper diet and after a few days began to vomit and have 
loose, undigested movements. A careful physical examina- 
tion, made by a physician who saw him July 11, showed the 
edge of the liver 2 cm. below the costal border in the nipple 
line. He was then cleaned out thoroughly and given only 
water. He was kept on water some days, nutrient enemata 
being given in addition. These were, however, not well re- 
tained. After about ten days he was given cereal waters, 
which he did not like and of which he took very little. He 
continued to have from three to four loose, yellow movements 
daily and, in consequence, he was given no milk until August 
I, when he was put on a mixture of one part of skimm.ed milk 
and three parts of arrowroot water. He took about twenty- 
four ounces of this mixture in twenty-four hours. His move- 
ments had become a little firmer since the milk was begun. 
He had been cleaned out thoroughly several times during the 
last three weeks and had had his bowels irrigated once or tw ice 
daily. He had been taking bismuth steadily, as well as three 
drops of whiskey every three hours. His temperature had 
varied from normal to 100° F. He lay quietly most of the 
time and seldom cried, although he occasionally whined. 
The physician had noticed a hard swelling in the abdomen 
about ten days before. It had steadily increased in size. He 
was seen In consultation August 4. 

Physical Examination. He was still a good -sized baby, 
although he had evidently lost much weight. He was very 

433 



434 CASE HISTORIES IN PEDIATRICS. 

pale and paid very little attention to anything that was done 
to him. The anterior fontanelle was 3 cm. in diameter and 
somewhat depressed. The bones of the skull did not overlap. 
There was no rigidity of the neck. There was a venous hum 
in the neck. The pupils were equal and reacted to light. 
The tongue was slightly coated ; the mouth and throat were 
normal. He had six teeth. The heart and lungs were normal. 
The upper border of the liver flatness in the nipple line was 
at the upper border of the fifth rib. The edge of the liver 
could be felt running across the abdomen just above the 
right anterior superior spine to the left costal border in the 
nipple line. The liver was hard, the surface smooth, the edge 
slightly rounded. It was slightly tender. The spleen was 
not palpable. The abdomen was otherwise normal. The 
extremities were normal except for slight edema of the feet. 
There was no spasm or paralysis. The knee-jerks were equal 
and feeble. Kernig's sign was absent. There was a fine pur- 
puric eruption on the abdomen and on the feet. There was 
no enlargement of the peripheral lymph nodes. The rectal 
temperature was 98° F. 

The urine was pale, acid in reaction, and of a specific 
gravity of 1,010. It contained neither albumin nor sugar. 

Diagnosis. The most striking thing in the physical examina- 
tion is the enlargement of the liver, which has developed in 
less than three weeks. This enlargement has come on too 
rapidly to be due to any form of cirrhosis ; it cannot be due to 
passive congestion, because the heart and lungs are normal; 
there is no cause for amyloid change; the enlargement is too 
uniform for malignant disease. The only reasonable ex- 
planation for the enlargement is fatty change. The cause of 
this fatty change is not difficult to find. He has had practi- 
cally no nourishment for more than three weeks, and must 
also have had a certain amount of toxic absorption from the 
intestines during this time. Disturbance of nutrition is one 
of the most common causes of fatty change in the liver, and 
intestinal toxemia in infancy almost always causes fatty 
degeneration of the liver. The pathological condition in the 
liver is undoubtedly a mixture of fatty infiltration and de- 
generation, the infiltration being the more Important. The 



DISEASES OF THE LIVER. 435 

hard, smooth surface and the slightly rounded edge are also 
characteristic of the fatty liver. The diagnosis of ** Fatty 
Liver "is, therefore, justified. 

The pallor and the venous hum in the neck are signs of 
anemia, which is undoubtedly also due to the disturbance of 
the nutrition from the lack of food. The purpuric eruption is, 
likewise, merely a sign of disturbed nutrition. 

Prognosis. The prognosis is a serious one. It is impossible 
to determine at once whether or not the disturbance of 
nutrition has progressed so far that recovery is impossible 
when proper food is given. Time alone can settle this point. 

Treatment. The only food which is likely to be utilized in 
this instance is human milk. This should be obtained at 
any cost. If he will not nurse or take it well from the bottle, 
it must be given through a tube passed through the mouth. 
If human milk cannot be obtained, a modified milk, low in 
fat and high in sugar and proteids, will be the best substitute. 
A mixture containing i.oo% of fat, 7.00% of sugar and 2.00% 
of proteids is a suitable one. He will probably digest the 
casein more easily, if the mixture is boiled for ten minutes 
or if citrate of soda, in the proportion of two grains to each 
ounce of milk and cream in the mixture, is added to it. There 
are no drugs that will help him. It is important, of course, 
to handle him as little as possible, to keep him warm and to 
give him a large supply of sunlight and fresh air. 



43^ CASE HISTORIES IN PEDIATRICS. 

CASE 133. William H.'s father and mother were living and 
well, as were three other children, one older and two younger 
than the patient. There had been no deaths in the family, 
but his mother had miscarried after her first child was born. 
He had had no known exposure to tuberculosis. He was born 
at full term and had always been well except for an attack of 
bronchopneumonia when he was a month old, and measles 
and mumps when he was three years old. His digestion 
had always been good. No history of alcoholism could be 
obtained. 

He had been running down since the early spring, but was 
still able to be up and about most of the time. He was often 
drowsy and frequently complained of headache. He had been 
more or less jaundiced since May. The skin was nearly clear 
at times, but the eyes were always yellow. His appetite was 
good and he did not vomit or complain of pain in the abdomen. 
The bowels moved daily ; the movements were rather light in 
color, but never gray or white. The urine was often dark 
colored and had recently stained his clothing yellow. He was 
seen September 26, when six years old. 

Physical Examination. He was well-developed and fairly 
nourished. The skin, conjunctivae and mucous membranes 
were distinctly yellow. His tongue was clean; his teeth in 
fair condition. The throat was normal. The cardiac impulse 
was palpable in the fourth space in the nipple line, 6 cm. to 
the left of the median line. The upper border of the relative 
cardiac dullness was at the upper border of the third rib, the 
right border 2 J cm. to the right of the median hne. The 
action was regular. The first sound was of fair strength, but 
w^as followed at the apex and pulmonic area by very faint 
murmurs, which were not transmitted. The second pulmonic 
sound was not accentuated. There was a venous hum in the 
neck. The lungs were normal. The upper border of the liver 
flatness was in the fifth space ; the lower border was palpable 
4 cm. below the costal border in the nipple line. The edge was 
somewhat rounded, the surface smooth. The gall bladder 
was not palpable, no masses could be made out, and the liver 
was not tender. The spleen was not palpable and was not 
enlarged to percussion. The abdomen was moderately dis- 



DISEASES OF THE LIVER. 437 

tended and the superficial veins in the upper portion enlarged. 
There was slight dullness In the flanks, but it did not change 
with change of position, and there was no fluid wave. The 
extremities were normal. There was no spasm or paralysis. 
The knee-jerks were equal and normal. There was no edema 
of the extremities. There was no enlargement of the periph- 
eral lymph nodes. There was no eruption and no scars of old 
eruptions. There were no mucous patches or rhagades. The 
rectal temperature was normal. 

The urine was dark In color, acid in reaction, of a specific 
gravity of 1,030, and contained the slightest possible trace 
of albumin and much bile, but no sugar. The sediment 
showed many small round cells, a few red blood corpuscles, 
leucocytes and squamous cells, and an occasional hyaline and 
fine granular cast. 

The stools were loose, brownish and foul, and were shown by 
chemical examination to contain bile pigment. 

The leucocyte count was 9,900. 

A skin tuberculin test was negative. 

Diagnosis. Syphilis of the liver can be ruled out on the good 
family history and the absence of all other signs of syphilis. 
Less important points against syphilis of the liver are the 
presence of jaundice and the absence of enlargement of the 
spleen. Tuberculosis of the liver can be excluded on the nega- 
tive tuberculin test. The facts that there are two murmurs, 
that they are not transmitted, that the second pulmonic 
sound is not Increased, that the heart is not enlarged and that 
there Is a venous hum in the neck show that the murmurs in 
the heart are anemic. The heart being otherwise normal, 
cirrhosis of the liver secondary to chronic adhesive peri- 
carditis can be eliminated. The presence of bile In the stools 
rules out chronic indigestion with obstruction of the large 
bile ducts. Abscess of the liver can be excluded on the 
absence of fever and the low white count. The marked jaun- 
dice and the beginning ascites are also against it. The smooth 
surface of the liver and the presence of jaundice without 
obstruction of the large ducts makes a new growth extremely 
improbable. The diagnosis is, therefore, by exclusion, 
Cirrhosis of the Liver. The absence of enlargement of the 



438 CASE HISTORIES IN PEDIATRICS. 

spleen, which is one of the earliest signs of hypertrophic 
cirrhosis, and without which this diagnosis is not justified, 
makes cirrhosis of the atrophic variety, in the pre-atrophic 
stage, the most probable diagnosis. There is nothing in the 
history to account for the development of the cirrhosis, since 
chronic alcoholism and disease of the gastro-enteric tract can 
be excluded. 

Prognosis. There is no chance for recovery. He will 
probably not live many months. 

Treatment. The treatment can be only symptomatic. 



DISEASES OF THE LIVER. 439 

CASE 134. Richard D. was seen in consultation when six 
years old. His mother had had a cancer of the breast removed 
eight years before. She was well for six years, when she had 
a recurrence in the liver and glands, and died a year later. 
He had always been well before the present illness. 

He had not been up to mark since an attack of chicken-pox 
several weeks before he was seen. There had, however, been 
no definite symptoms. Enlargement of the abdomen and of 
the superficial lymph nodes was first noticed a week before. 
The abdomen had increased in size very rapidly during the 
week. His appetite had fallen off, but there had been no 
nausea, vomiting or pain in the abdomen. The bowels had 
moved regularly ; the movements were of good color and 
looked perfectly digested. He had lost weight, strength and 
color very rapidly during the week. The temperature had 
been moderately elevated during the early part of the week, 
but had been normal for three days. 

Physical Examination. He was well developed and nour- 
ished, but had evidently lost considerable weight and color. 
There was no jaundice. The tongue was nearly clean; the 
throat normal. The heart and lungs were normal. The 
abdomen was much enlarged and there was distinct bulging 
in the epigastrium. The superficial abdominal veins were 
moderately enlarged. The upper border of the liver flatness 
in front was at the lower border of the fifth rib; behind, in 
the eighth space on the right and the ninth space on the left 
side. The lower border of the liver reached to the right 
anterior superior spine, ran across the abdomen midway 
between the pubes and the navel and thence nearly to the 
left anterior superior spine. The left border was concealed 
by the greatly enlarged spleen, which filled up the left flank 
and overlapped the liver. The surface of the liver was 
markedly irregular. Several masses, the size of hens* eggs, 
were easily felt, and there was one, the size of an orange, in 
the epigastrium. The liver was slightly tender. There were 
no evidences of fluid in the abdomen. The kidneys were not 
palpable. There was no edema of the extremities, which were 
normal. There was no spasm or paralysis. The knee-jerks 
were equal and normal. Kernig's sign was absent. There 



440 CASE HISTORIES IN PEDIATRICS. 

were numerous lymph nodes, varying in size from that of a 
bean to that of a walnut, in the neck, a few small ones in the 
axillae, and several, the size of marbles, in the groins. 

The urine was normal in color, acid in reaction, of a specific 
gravity of 1,015 ^.nd contained neither albumin, sugar nor 
bile. The sediment showed nothing abnormal. 

Stained specimens of the blood showed slight achromia, but 
no irregularity in the size or shape of the red corpuscles and 
no nucleated forms. There were no plasmodia and no leu- 
cocytosis. There were fifty-four polymorphonuclear neu- 
trophils to forty-six mononuclear cells. 

Diagnosis. The diagnosis lies between malignant disease 
of the liver and acute lymphatic leukemia in an aleukemic 
stage. The points which suggest leukemia most strongly are 
the enlargement of the spleen and of the peripheral lymph 
nodes. It is true that in very rare instances there are times 
in the course of acute leukemia in which the number of white 
cells is not increased. In such instances, however, the pro- 
portion of mononuclear cells remains much higher than in 
this instance, in which the number of mononuclear cells is not 
much above the normal limit. Primary malignant disease of 
the liver is extremely rare, there being but thirty-nine cases 
on record. The trouble in the liver in this instance is, there- 
fore, almost certainly secondary. The usual location of the 
primary lesion is in the suprarenal capsule. The enlargement 
of the spleen and lymph nodes is, therefore, like that of the 
liver, probably due to metastatic malignant involvement 
rather than to leukemia. The diagnosis of secondary Malig- 
nant Disease of the Liver is, therefore, justified. Sarcoma 
of the suprarenal capsule is much more common than carci- 
noma. The chances are, therefore, that the disease of the 
liver in this instance is sarcoma. The fact that his mother 
had a carcinoma is in all probability merely a coincidence. 

Prognosis. The prognosis Is, humanly speaking, abso- 
lutely hopeless. He will probably not live but a few weeks. 

Treatment. It will be well to try the mixed toxins of the 
streptococcus of erysipelas and the bacillus prodigiosus, 
recommended by Coley. Little or nothing can be hoped from 
them, however, in this instance. 



SECTION X. 

DISEASES OF THE KIDNEYS AND BLADDER. 

CASE 135. Walter B., fourteen years old, had had measles, 
whooping cough, chicken-pox, influenza and tonsillitis, but 
not scarlet fever, diphtheria or rheumatism. His urine had 
been examined from time to time in the past, but had never 
contained albumin. He had an acute attack of appendicitis 
the latter part of December, 1909, which required operation 
and drainage. He had been below par for some time before 
this operation and had not been well since then, although he 
had had no very definite symptoms. He was easily tired, did 
not feel able to go to school and did not care to play. His 
appetite and digestion were good. He had no cough or fever. 
His chief complaint was of pain in the left iliac fossa, which 
was not dependent on either food or exertion. Micturition 
was at times a little painful, but was not increased in fre- 
quency. He thought that he did not pass any more urine than 
normal, and did not have to get up at night. He had always 
been thin and had lost some weight since the operation. He 
was seen at 2 p.m.. May 27, 1910. 

Physical Examination. He was thin and rather flabby, 
but not pale. He looked pulled down and was very nervous. 
His tongue was clean. His heart was normal except that at 
times the rhythm was a little irregular. The lungs were 
normal. The liver and spleen were not palpable. The ab- 
domen was sunken and showed nothing whatever abnormal 
except the scar of the operation. The kidneys were not 
palpable. The genitals were normal. The extremities were 
normal. There was no spasm or paralysis; the knee-jerks 
were equal and normal. There was no edema and no 
enlargement of the peripheral lymph nodes. 

The freshly passed urine was normal in color, clear, alka- 
line in reaction, of a specific gravity of 1,025, and showed a 
trace of albumin with nitric acid. The centrifugalized sedi- 

441 



442 CASE HISTORIES IN PEDIATRICS. 

ment showed a few small, round cells and no bacteria. The 
gravity sediment showed neither cells, casts nor blood. 

Diagnosis. It is evident, in the first place, that the pain 
in the abdomen has no connection with the albumin in the 
urine. It is almost certainly due to adhesions formed at the 
time of the appendicitis. A bacterial infection of the urinary 
tract can be excluded on the absence of bacteria and pus 
corpuscles in the urine. The other possibilities are chronic 
nephritis and orthostatic albuminuria. His age and the fact 
that he does not get up at night to pass water are much against 
chronic interstitial nephritis. He has not had scarlet fever 
or diphtheria, the usual precursors of chronic parenchymatous 
nephritis at this age, and has never at any time had any 
symptoms of acute nephritis. The absence of all organic 
elements in the sediment, moreover, while possible in chronic 
interstitial nephritis, is very unusual; it practically excludes 
chronic parenchymatous nephritis. The high specific gravity 
is against chronic interstitial nephritis; the small amount of 
urine against chronic parenchymatous nephritis. The normal 
condition of the urine at various examinations in the past is 
also very much against the existence of any form of chronic 
nephritis. His age and slight build are in favor of orthostatic 
albuminuria. So also is the impaired muscular tone resulting 
from his enfeebled condition after the operation, which pre- 
disposes him to lordosis, the probable cause of orthostatic 
albuminuria. Although the diagnosis of orthostatic albumi- 
nuria seems reasonably certain, it will be wise to examine the 
urine further in order to settle the diagnosis. The albumin in 
orthostatic albuminuria is present only in the urine excreted 
when the patient is in the upright position. It is usually 
constantly present in interstitial nephritis or, if not, there is 
no regularity about its appearance. More urine is passed 
during the day than during the night in orthostatic albumi- 
nuria, while the reverse is the case in chronic interstitial 
nephritis. The total amount of the urine is unchanged in 
orthostatic albuminuria, while it is increased in interstitial 
nephritis. 

The twenty-four-hour amount of urine was thirty-one 
ounces. Twelve ounces were passed during the night and 



DISEASES OF THE KIDNEYS AND BLADDER. 443 

nineteen ounces during the day. The urine passed on getting 
up in the morning was pale, clear, acid in reaction, of a specific 
gravity of 1,030, and showed no albumin by either the heat 
or nitric acid tests. That passed during the morning was pale, 
clear, acid in reaction, of a specific gravity of 1,032 and showed 
a trace of albumin by the nitric acid test. That passed dur- 
ing the afternoon was pale, clear, acid in reaction, of a specific 
gravity of 1,030, and showed a slight trace of albumin by 
the nitric acid test. No cells or casts were found in the 
gravity sediment of any of the specimens. The diagnosis of 
Orthostatic Albuminuria is thus confirmed. 

Prognosis. The prognosis of this condition is good. It 
probably never leads to chronic nephritis. The duration is 
indefinite. It will probably persist in this instance until he 
gets back into good physical condition and grows heavier and 
more muscular. 

Treatment. There is no specific treatment. The treat- 
ment consists in regulation of his life with the object of getting 
him into good general condition as soon as possible. It is 
not necessary to diminish the proteids in his diet. It will, 
however, be advisable for him to lie down for a time daily. 



^^ CASE HISTORIES IN PEDIATRICS. 

CASE 136. Harry D., eleven years old, had had frequent 
attacks of recurrent vomiting since he was a baby. He had 
had an attack of infantile paralysis, involving both legs and 
one arm, two months before. Nausea and vomiting began 
November 2 1 and continued in spite of several doses of calo- 
mel, which resulted in a number of large, well-digested move- 
ments. He had taken and retained very little nourishment, 
and had, in consequence, lost considerable weight and strength. 
He had had no fever. The urine passed during the day of the 
26th was clear but small in amount. That night he had con- 
siderable pain in the abdomen, especially on the left side. 
It was not very severe and not paroxysmal. It did not run 
down into the penis, and micturition was not frequent or 
painful. The urine passed during the night was not dimin- 
ished in amount but was distinctly bloody. He was rather 
lame the morning of the 27th, but had no pain. The urine 
continued to be bloody. His bowels moved well, but he 
continued to vomit. His mouth temperature rose to 1 01^ F. 
He was seen in consultation at noon, November 27. 

Physical Examination. He was fairly developed and nour- 
ished and a little pale. His tongue was dry and covered with a 
thin, brown coat. The cardiac area was normal, the sounds 
fairly strong, the action regular, the rate 120. The lungs were 
normal. The liver and spleen were not palpable or enlarged 
to percussion. The abdomen was much sunken. There was 
slight tenderness on deep pressure in the left flank, but no 
muscular spasm, dullness or tumor. The kidneys were not 
palpable and there was no tenderness over the ureters. The 
genitals were normal. The extremities were not examined. 

The urine was red, strongly acid in reaction, of a specific 
gravity of 1,020 and contained a trace of albumin, consider- 
able acetone and a little diacetic acid, but no sugar. The 
sediment was very abundant and was almost entirely com- 
posed of acid sodium urate crystals. It also contained a 
moderate number of normal red blood corpuscles and an 
occasional leucocyte, but no other cells or casts. 

Diagnosis. He undoubtedly has one of his ordinary attacks 
of recurrent vomiting. The disturbance of metabolism at the 
bottom of the attack, the insufficient supply of food, or both 



DISEASES OF THE KIDNEYS AND BLADDER. 



445 



together, explain the presence of acetone and diacetic acid 
in the urine. The pain in the abdomen and the hematuria 
require further explanation. The condition is an acute one, 
and the examination of the kidneys shows nothing abnormal. 
It is unnecessary, therefore, to consider such conditions as 
sarcoma or tuberculosis of the kidney. Acute nephritis is 
seldom accompanied by pain. It can be excluded on the 
absence of cells and casts. The most probable explanation 
would, at first thought, seem to be a renal calculus. The 
pain was, however, not localized or paroxysmal and did not 
run down into the penis. Micturition was not painful or 
increased in frequency. These facts do not, of course, rule 
out a renal calculus, but make it less probable than at first 
appeared. A large number of sharp crystals in the urine 
might easily irritate the kidney sufficiently to cause the sort 
of pain present in this instance and hematuria. It is hard to 
conceive of anything sharper than the crystals of acid sodium 
urate which were so numerous in this boy's urine. Irritation 
of the kidneys and urinary tract from crystals of acid sodium 
urate is, therefore, the most reasonable explanation of the 
Hematuria. The disturbance of metabolism at the root of 
the recurrent vomiting, together with that due to an insuffi- 
cient supply of food, and the concentration of the urine resulting 
from an insufficient supply of water, account satisfactorily for 
the formation of the acid sodium urate crystals. 

Prognosis. The prognosis is good. The attack of recur- 
rent vomiting will yield quickly to treatment. The hematuria 
will cease with relief of the attack of vomiting, and probably 
sooner if more water can be introduced into the system. 

Treatment. See Case 2^] for the treatment of recurrent 
vomiting. The indications for the treatment of the hematuria 
are to increase the amount of the urine and diminish its 
acidity. These can best be met by high injections of from 
eight to twelve ounces of a solution of one teaspoonful of 
bicarbonate of soda in eight ounces of water every four 
hours. The same solution may be given by mouth, in tea- 
spoonful or tablespoonful doses, every fifteen or twenty min- 
utes. Fortunately, this method of treatment is also the one 
most useful in recurrent vomiting. 



446 CASE HISTORIES IN PEDIATRICS. 

CASE 137. Frances S., two and one-half years old, was the 
child of healthy parents. Three other children were living 
and well; none had died, but there had been two miscarriages. 
There was no history of tuberculosis in the family and there 
had been no known exposure to it. 

She had always been well and strong. She had a cough for 
a few days about the loth of August. Her parents noticed 
at this time that her eyelids were a little swollen in the morn- 
ing. Not much was thought of it, however, as the swelling 
was gone by noon. It became more marked about a week 
later and had persisted. Swelling of the legs and abdomen 
also appeared in a few days and had steadily increased. It 
was noticed at this time that she was not passing as much 
urine as usual. She was put on an exclusively milk diet, which 
she took well. Her bowels had been kept well open by 
cathartics. She was admitted to the Children's Hospital, 
September 7. 

Physical Examination. She was markedly pale, but did 
not appear very sick. There was marked general anasarca. 
Her eyelids were so much swollen that it was difificult to see 
her eyeballs. The pupils were equal and reacted to light. 
Her tongue was considerably coated. Her teeth were in bad 
condition and there was a slight pyorrhea alveolaris. The 
tonsils were ragged and injected. There was a venous hum 
in the neck. The cardiac impulse was neither visible nor 
palpable, probably because of the anasarca. The upper 
border of the relative cardiac dullness was in the second space, 
the right border 2J cm. to the right, and the left border 5 cm. 
to the left of the median line. The first sound was of good 
strength and was followed at the mitral area by a soft murmur, 
which was not transmitted. The second pulmonic sound was 
not accentuated. There was slight dullness, with diminished 
vesicular respiration and numerous fine, moist rales, below 
the sixth rib and extending outward to the mid -axillary line 
on both sides. The upper border of the liver flatness was in 
the fifth space in the nipple line ; the edge was not palpable. 
The spleen was not palpable. The abdomen was much and 
symmetrically distended. The superficial veins were not 
enlarged. The percussion note was flat over the whole ab- 



DISEASES OF THE KIDNEYS AND BLADDER. 447 

domen except in the epigastrium, where it was tympanitic. 
The upper border of the flat area was concave. The area of 
flatness changed with change of position, and there was a 
fluid wave. There was no spasm or paralysis of the extremi- 
ties. The knee-jerks were equal and normal. There was no 
enlargement of the peripheral lymph nodes. There was no 
eruption or desquamation. The rectal tem^perature was 
100° F., the pulse no, the respiration 30. 

Four ounces of urine were passed in the first twenty-four 
hours of her stay in the hospital. It was brownish in color, 
turbid, acid, of a specific gravity of 1,030 and contained 
twenty grams of albumin per liter, but no sugar or acetone. 
The sediment showed large numbers of hyaline, fine and 
coarse granular casts, and a few blood casts, as well as large 
numbers of red and white blood cells. 

Diagnosis. She undoubtedly has Acute Nephritis. The 
normal size of the heart and the absence of accentuation of 
the second aortic sound prove that there is no chronic trouble 
back of it. The etiology is obscure. The ragged, injected 
tonsils or the diseased teeth and gums may have been the 
portal of entry for the infection. The venous hum in the neck 
and the murmur in the heart are anemic in origin and 
unimportant. 

Prognosis. The prognosis is grave. She is passing but little 
urine and has general anasarca, ascites and edema of the 
lungs. A more definite prognosis can be given in a few days 
after it has been seen how well she responds to treatment. 
If she responds quickly, she will probably recover entirely in 
time. If she does not respond, she will probably not live 
many days. 

Treatment. Her kidneys are congested and engorged with 
blood, the glomeruli and tubules are blocked and the epithe- 
lium degenerated. They are able to excrete but little and are 
practically impervious to water. If they were not, she would 
not be edematous. Water must, therefore, be stopped en- 
tirely for the present. It ought not to be given again until the 
kidneys have begun to excrete fairly freely and the edema and 
ascites are diminishing. 

Her kidneys should be spared the work of excretion as 



448 CASE HISTORIES IN PEDIATRICS. 

much as possible. The products of the metabolism of certain 
foods are excreted with difficulty, and those of others easily. 
Those substances which are excreted with the most difficulty 
are urea, creatinin and phosphoric acid. Urea is derived 
from proteids: meat, eggs and milk. It would seem wise, 
then, to cut out all proteids from her diet. Nothing is gained, 
however, by reducing them below a certain point, because, 
even in starvation, a certain amount of urea is formed as the 
result of the destruction of the body tissues. If enough pro- 
teid is given to cover this nitrogenous waste, the body tissues 
are saved and the kidneys are not worked any harder than 
when no proteid is given. The amount of proteid required to 
balance the necessary nitrogenous metabolism of the body is 
known as the minimum proteid need, and is, in a child of this 
age, about twenty grams. Creatinin is derived from creatin. 
This is contained in meat and especially in meat extracts and 
meat broths. Meat extracts and broths contain little else and 
have but little nutritive value. They should, therefore, be 
entirely excluded from her diet. Milk contains but little 
creatinin. Phosphoric acid is present in large amounts in 
meats, yolk of egg, milk and many vegetables. The addition 
of calcium carbonate to the food, however, prevents its 
passage through the kidneys and causes it to be excreted by 
the intestines. The products of the metabolism of fat, sugars 
and starches are excreted by the kidneys without much 
difficulty. 

It is not only necessary, however, to cover her proteid need, 
but also to cover her caloric needs. These are a little under 
1,000 calories. She can get along very well for a time, how- 
ever, on 800 or 900 calories. 

The problem is, then, to lay out a diet for her which will 
contain 800 or 900 calories and about 20 grams of proteid. 
The best form in which to give the proteid is milk. Six hun- 
dred cubic centimeters of milk will give 21 grams of proteid, 
but only about 400 calories. If milk enough is given to fur- 
nish 900 calories it will contain 47 grams of proteid, which is 
more than double the minimum proteid need. The disad- 
vantages of an exclusively milk diet are thus evident. If 
200 ccm. of gravity cream (16% fat) is substituted for 200 



DISEASES OF THE KIDNEYS AND BLADDER. 



449 



TABLE OF FOOD VALUES 









Grams. 




Calories 


F. 


C. P. 


Whole milk, i quart, 


670 


38 


43 


34 


Skimmed milk, i quart, 


400 


10 


43 


35 


Gravity cream, i pint, 


860 


77 


22 


14 


Buttermilk, i quart, 


360 


5 


43 


35 


WTiey, I quart 


260 


5 


43 


9 


Beef juice, i oimce, 


10 


* 




2 


Crackers, i ounce,i 


120 


3 


20 


3 


Bread, i slice,^ 


75 


* 


15 


3 


Zwiebach, i slice,' 


120 


3 


20 


3 


Shredded wheat biscuit, 


105 


* 


22 


3 


Rolled oats (cooked), i tablespoonful,* 


35 


* 


6.5 


i-S 


Cream of wheat, Ralston and similar cereals (cooked), 










I tablespoonful,^ 


40 




8.5 


1-5 


Potato, size of large egg, 


70 




15 


2 


Macaroni (cooked), i tablespoonful,* 


30 


* 


5 


I 


r WTiole 
Egg \ Yolk, 


72 


5 




7 


60 


5 




4 


I White, 


12 






3 


^ "1 (cooked), I ounce,^ 


60 


3 




7 


Bacon, i slice = 3^ ounce. 


90 


9 




i-S 


Butter, iM inches cube = i ounce. 


225 


24 






OUve oil, I tablespoonful. 


125 


14 






American cheese, i3^ inches cube = i ounce. 


130 


10.5 




8.5 


Cream cheese, i}4 inches cube = i ounce. 


130 


10.5 




8.5 


c / Cane, i rounded teaspoonful, 
I Milk, I rounded tablespoonful, 


25 




6 




60 




IS 





^ \ (cooked,) I tablespoonful,* 

Carrots 

Squash 

Turnip } (cooked), i tablespoonful,* 

Beets 

Onions 

Orange, medium sized, 

Apple, medium sized, 

Banana, 

Prunes, 4, without sugar, 



40 



30 



50 


13 


70 


17 


IIS 3 


[ 24 


30 


7 



Clear soups and broths made without rice or barley have practically no nutritive value. 
The nutritive value of the "fodder" vegetables, such as spinach, string beans, asparagus, lettuce, 
celery, cauliflower, cabbage, egg plant, tomatoes and cucumbers, is so slight that they may be disregarded. 
Pears and peaches have about the same value as apples of tlie same size. 

1 Crackers vary so much in size that they must be weighed to determine bow many it takes to weigh 
an ounce. 

2 Bread, i slice four inches square and three-eighths thick = i ounce. 
^ Zweibach. i slice = large slice. 

* A tablespoonful means as in ordinary serving, not level. 

^ The lean of a lamb chop weighs about an ounce; so does a piece of meat about i 1-4 inches cube 
or a thin slice of beef. 

* These foods contain from one-quarter to one-half gram of fat in each of the quantities given. 



450 CASE HISTORIES IN PEDIATRICS. 

Table of Average Caloric and Protein Needs 





Calories 
per Kilo 




Total 
Calories 


Average 
Protein Needs 


Total Average 
Protein Needs 


0-6 mos. 
6-12 mos. 


I00-I20 
lOO 




. 


1.5 to 2.0 grams per Kilo 




1-2 >t:s. 

4 yrs. 

8 3t:s. 

12 yrs. 


go 

75 
6o 

SO 


I200 
1400 
1600 


plus 
plus 
plus 


3.5 grams " " 
2.5 grams " " 
2.0 grams " '* 


55 grams 
60 grams 
75 grams 



The minimum protein needs are approximately three-fifths of the average protein 
needs. 

com. of milk, the mixture will provide 600 calories. The 
remainder of the caloric need can be met by giving sugar and 
Starch. For example, as is shown in the preceding table of 
food values, two tablespoonfuls of cereal will give 80 cal- 
ories, two teaspoonfuls of sugar 50 calories, one slice of bread 
75 calories, and a piece of butter one inch square and one- 
half inch thick, about 65 calories, making a total of 870 cal- 
ories, which covers fairly satisfactorily her caloric needs, and 
does not add much to the proteids. 

The addition of 30 grains of prepared chalk to the milk and 
cream mixture will probably render the phosphoric acid prac- 
tically inert. The chief objection to the milk in this instance 
is the water which it contains, a little more than a pint. In 
her present condition even this amount of water may do harm. 
It will be wise, therefore, to disregard her proteid needs for 
twenty-four or forty-eight hours and give her nothing but 
carbohydrates and fat. In fact, it will do her no harm if 
she takes no nourishment at aU for twenty-four or forty- 
eight hours. 

There are no drugs which can directly aid her kidneys to do 
their work. Digitalis and drugs of its class have no direct 
action on the kidneys, but increase the flow of urine by 
strengthening the action of the heart and thus sending more 
blood through the kidneys. Her kidneys are already engorged 
with blood. It is, therefore, not only irrational to increase 
the flow of blood to her kidneys, but also very likely to in- 
crease the trouble. Caflein, theobromin and their prepara- 
tions have a direct stimulant action on the renal epithelium. 
Her renal epithelium is in no condition to respond to stimula- 
tion and, moreover, stimulation may do harm by increasing 
the inflammation. The action of alkalies is probably the 



DISEASES OF THE KIDNEYS AND BLADDER. 45 1 

same as that of other diffusible bodies which are excreted by 
the kidneys and which during their excretion increase the 
flow of urine. As the object of the treatment is to spare the 
kidneys, it hardly seems rational to give alkalies at this time 
to increase the work which they have to do. All drug treat- 
ment is, therefore, contra-indicated. 

It is possible, however, to spare the kidneys by making the 
bowels do part of their work. She must, therefore, be made 
to have three or four large, watery movements of the bowels 
daily. Compound jalap powder, in doses of fifteen grains, or 
compound licorice powder, in doses of from one to two tea- 
spoonfuls, will probably do this best in this instance, as she 
will probably not object to them as she would to concentrated 
solutions of Epsom salts, the ideal cathartic in this condition. 
The free catharsis will also help to diminish the edema. 

It is important to get rid of the edema. The best way to 
accomplish this is by free diaphoresis. This spares the kid- 
neys by getting the water out of the system, but does not save 
them in other ways, because it is certain that but little urea 
is eliminated in this way, and there is no proof that toxic 
substances are excreted by the skin. Pilocarpin is the only 
diaphoretic drug powerful enough to be of any practical 
utility. It is, however, a very dangerous drug on account of 
its liability to cause edema of the lungs, and should never be 
used except in an emergency. Her condition is not serious 
enough to justify its use. The application of heat externally 
is far safer and usually more effectual. It is very difficult to 
keep a child in a hot-air bath long enough to get good results, 
as they soon become restless and kick the coverings loose. 
They object much less to hot packs. She should be wrapped 
in a blanket and put in a tub of water between 105° F. and 
110° F. and kept there from ten to fifteen minutes. She 
should then be taken out, wrapped in a hot, dry blanket and 
kept surrounded by heaters for from one-half to two hours. 
This should be repeated daily as long as there is much edema. 



452 



CASE HISTORIES IN PEDIATRICS. 



CASE 138. Nora C, aged thirteen months, lived in a town 
in which malaria was common. She was breast-fed for five 
months. She was then weaned gradually and put on a " hit- 
or-miss " mixture of top milk with Mellin's Food, on which 
she did very well. Early in August, about three weeks before 
she was seen, she began to be feverish and was given calomel. 
The next day she was better, but two days later she had a 
chill. She had had no chills since then, but had sweat pro- 
fusely at times and had lost much weight. Her temperature 
had not been normal but once in the last two weeks, and had 
been very irregular. The food had been changed to a weak 
top milk and barley water mixture. She had not vomited, 
but had been constipated. The movements, however, were 
normal in character. The Widal reaction, tested three days 
before, was negative. The diagnosis of malaria having been 
made, on the basis of the irregular temperature, the chill, the 
sweating and the negative Widal test, she had been given 
quinine in considerable doses during the last six days without, 
however, any improvement in the symptoms. 

Physical Examination. She was well developed and nour- 
ished, but a little pale and flabby. The anterior fontanelle 
was 3 cm. in diameter and level. She was irritable, but not 
stupid. Her mouth and throat showed nothing abnormal. 
She had eight teeth. There was no rosary. The heart, lungs 
and abdomen showed nothing abnormal. The liver was 
palpable 2 cm. below the costal border in the nipple line. 
The spleen was not palpable. The extremities were normal. 
There was no spasm or paralysis. The knee-jerks were equal 
and normal. There was no enlargement of the peripheral 
lymph nodes. 

The blood showed 80% of hemoglobin, and 37,600 white 
corpuscles. 

Diagnosis. The negative Widal test and the leucocytosis 
rule out typhoid fever. The absence of enlargement of the 
spleen and the leucocytosis, as well as the failure of the quinine 
to influence the symptoms, exclude malaria. The fever, chills, 
sweating and leucocytosis point to a purulent process some- 
where. There is nothing about the symptomatology to sug- 
gest the location of this process. In such instances the middle 



DISEASES OF THE KIDNEYS AND BLADDER. 453 

ear and the urine must always be investigated, since in infancy 
both otitis media and pyelitis often cause marked general, 
without any local, symptoms. If the trouble is not found in 
one, it is almost certain to be found in the other. If both are 
normal, the trouble is most often tubercular. 

The ears were examined and found normal. 

The fresh urine was cloudy, pale, neutral in reaction and 
contained a very slight trace of albumin. The sediment ob- 
tained by centrifugalization showed very many pus cells, 
free and in clumps, a few small round, squamous, oval and 
caudate cells, and many motile bacteria. These bacteria 
were later shown to be colon bacilli. 

The diagnosis is, therefore, Pyelitis, or, better, infection 
of the urinary tract by the bacillus coli. 

Prognosis. There is practically no danger as to life. She 
will probably recover in a few weeks, but there is a reasonable 
possibility that the condition will persist, with intermissions, 
for many months. In some instances the urine continues to 
contain bacteria, and at times pus, for years, although there 
is no constitutional disturbance. There is very little danger 
that the process will extend to the kidney tissue or that it 
will involve anything more than the superficial layers of the 
pelvis and bladder. 

Treatment. Local treatment of the bladder is of compara- 
tively little value because the infection is not localized in 
the bladder but involves the whole urinary tract. It is better, 
therefore, not to use it in this instance. Hexamethylenamin, 
the best drug of its class, liberates formaldehyde readily in the 
urine and has a strong antiseptic action. Unfortunately the 
colon bacillus is comparatively insusceptible to its action. 
Hexamethylenamin is usually less effective than the alkalies, 
which, in spite of the fact that the colon bacillus grows more 
luxuriantly in alkaline than in acid media, are often very 
useful. It will be well, therefore, to give her ten grains of the 
citrate of potash, well diluted, three times a day. If this dose 
is not sufficient to make the urine highly alkaline, larger doses 
must be given. If the urine does not clear up under this treat- 
ment, hexamethylenamin, in doses of from one-half grain to 
one grain, three times a day, should be tried. If formalde- 



454 CASE HISTORIES IN PEDIATRICS. 

hyde is not found in the urine by Burnham^s test, the dose 
must be increased. It must not be forgotten that hexa- 
methylenamin is broken up only in an acid medium. Un- 
less the urine is strongly acid, acid sodium phosphate should, 
therefore, also be given. It is evident that an alkali should 
never be given at the same time as hexamethylenamin. If 
the trouble still persists, it will be well to try the effect of 
suddenly changing the reaction of the urine every three of 
four days, which sometimes clears up the urine very quickly. 
It can be made alkaline with the citrate of potash or bi- 
carbonate of soda, and acid with benzoic acid or acid sodium 
phosphate. Sufficient doses of these drugs must be given 
to make the urine strongly alkaline or acid, as the case may 
be. In order to determine whether the desired action is 
being obtained or not, the urine must be tested frequently 
with litmus paper. Reasonable beginning doses in this in- 
stance are from five to ten grains of citrate of potash or 
bicarbonate of soda and from one to three grains of benzoic 
acid or acid sodium phosphate, three times daily. 

If the trouble still continues, the vaccine treatment may be 
tried, but too much must not be hoped from it. In some in- 
stances it works very well; in others it has no effect v/hatever. 
An autogenous vaccine must be used. It will be well to begin 
with 25,000,000 every three or four days, increasing the dose 
rather rapidly to 100,000,000. The treatment can be carried 
on satisfactorily without determinations of the opsonic index. 



DISEASES OF THE KIDNEYS AND BLADDER. 455 

CASE 139. Mary W., aged seven months, was taken sud- 
denly sick with high fever the night of July 7. No cause for 
the fever could be made out. The temperature ran between 
103° F. and 105° F. up to the time she was seen in consulta- 
tion, July 14. The physical examination had always been 
negative. She had had a slight cough in the beginning. She 
had taken her food poorly, but had vomited but once. The 
bowels had moved regularly and the movements had been 
normal. She had always been conscious, but during the last 
two days had seemed tender all over and had held her head 
backward. During the last two or three days micturition had 
been painful but not increased in frequency, and the urine 
had left greenish-yellow spots on the diapers. 

Physical Examination. She was well developed and nour- 
ished, but had evidently lost some weight and color. She was 
conscious, but irritable. The anterior fontanelle was 3 cm. 
in diameter and depressed. There was no rigidity or tender- 
ness of the neck and no neck sign. The pupils were equal and 
reacted to light. The ear-drums were normal. The tongue 
was dry, the throat and gums normal. There were four teeth. 
The heart, lungs and abdomen were normal. The liver was 
just palpable in the nipple line. The spleen and kidneys were 
not palpable. The extremities were normal. There was no 
spasm or paralysis. The knee-jerks were equal and normal. 
Kernig's sign was absent and there was no contralateral 
reflex. There was no enlargement of the peripheral lymph 
nodes. The rectal temperature was 103.6° F., the pulse 160, 
the respiration 40. 

A stool which was seen was loose, smooth, yellow and 
contained no curds or mucus. There were several small 
spots, looking like pus, on the diaper. 

Diagnosis. The most probable diseases in this instance are 
pneumonia, cerebrospinal meningitis and pyelitis. The 
sudden onset, the continued high fever and the slight cough 
suggest pneumonia, but the absence of physical signs after a 
week and the fact that the rate of the respiration is not in- 
creased out of proportion to that of the pulse make it ex- 
tremely improbable. Meningitis is suggested by the history 
of general tenderness and of the tendency to hold the head 



456 



CASE HISTORIES IN PEDIATRICS. 



backward. It can be ruled out at once, however, on the de- 
pressed fontanelle and the absence of all signs of meningeal 
irritation or increased cerebral pressure. A lumbar puncture 
was done, however, at the request of the attending physician. 
The fluid ran out slowly, drop by drop, was perfectly clear, 
did not form a fibrin clot and contained no cells or bacteria 
(for description of the cerebrospinal fluid in health and 
disease see Case 72), thus proving that the trouble was not 
meningitis. 

The continued high fever without physical signs and with 
normal ears suggests at once the possibility of pyelitis. The 
painful micturition and the greenish-yellow spots on the 
diapers make this diagnosis almost certain. The urine was, 
therefore, obtained with a catheter. It was pale, turbid, acid 
in reaction and contained many pus cells and motile bacteria, 
which were later proved to be colon bacilli. The results of 
this examination confirm, of course, the diagnosis of 
Pyelitis. 

Prognosis. See Case 138. 

Treatment. See Case 138. 



DISEASES OF THE KIDNEYS AND BLADDER. 457 

CASE 140. Catherine R. was the fourth child of healthy 
parents. There had been no deaths or miscarriages. She had 
not, as far as known, been exposed to tuberculosis. 

She was born at full term after a normal labor and was 
normal at birth. She was breast-fed, but was given in addi- 
tion bread, potatoes and, in fact, a taste of almost everything 
on the table. Her digestion was good in spite of her faulty 
diet, and she gained steadily in weight up to an attack of 
bronchitis, w^hen she was nine months old. She did not seem 
as well after the bronchitis and ceased to gain, although her 
appetite and digestion continued good. Enlargement of the 
abdomen was noticed when she was nine and a half months 
old, and had increased rapidly since then. The abdomen had 
not been tender and the urine had never been red. She was 
seen in consultation when ten months old. 

Physical Examination. She was fairly developed and nour- 
ished. Her skin was pale, but her lips were red. The anterior 
fontanelle was 2 cm. in diameter and level. She had four 
teeth. Her tongue was clean and her throat normal. There 
was no rosary. Her heart and lungs were normal. The liver 
was palpable 3 cm. below the costal border in the nipple line. 
The spleen was not palpable. The left half of the abdomen 
was nearly filled by a hard, smooth, rounded mass. It had 
no definite borders, was flat on percussion and not at all 
tender. It filled the flank and evidently originated deep in 
the abdomen. It was not movable and its position was not 
influenced by the respiration. The abdomen showed nothing 
else abnormal. The extremities were normal and there was 
no edema. There was no spasm or paralysis; the knee-jerks 
were equal and normal; Kernig's sign was absent. There 
was no enlargement of the peripheral lymph nodes. The 
mass could be felt on rectal examination. 

Stained smears of the blood showed no changes in the red 
corpuscles and no leucocytosis. A large majority of the 
white corpuscles were lymphocytes, although there was a 
slight excess of eosinophiles. 

Diagnosis. The location of the mass deep down in the 
flank and its rounded character, without definite borders, 
prove that it is not a tumor of the spleen. The tumors in 



458 CASE HISTORIES IN PEDIATRICS. 

caseous or fibrocaseous tubercular peritonitis are not as large, 
are irregular in outline and usually multiple. Enlargement 
of the retroperitoneal lymph nodes might cause a tumor in 
this region, but it would not be as large and would be irregular 
in outline. The only organ whose enlargement would cause 
a tumor in this location is the left kidney. This tumor must, 
therefore, be the left kidney. The possible causes of enlarge- 
ment of the kidney are hydronephrosis, pyonephrosis and 
sarcoma. Hydronephrosis is extremely rare at this age, she 
has had no attacks of pain and there is no fluctuation. Pyo- 
nephrosis is also extremely uncommon at this age, there is 
nothing in her history to suggest an infection of the urinary 
tract, she has no fever or leucocytosis, her general condition 
is good and there is no fluctuation. Sarcoma of the kidney is 
more common at this age than at any other, it develops 
insidiously without much disturbance of the nutrition, and 
the tumor in this instance corresponds in its physical char- 
acteristics to those of sarcoma of the kidney. The eosino- 
philia is also suggestive of a new growth. The absence of 
hematuria does not count against sarcoma, because it occurs 
in but a small proportion of the cases. The diagnosis of 
Sarcoma of the Kidney is, therefore, justified. 

Prognosis. The prognosis without operation is absolutely 
hopeless. She will probably not live more than three or four 
months. It is not much better with operation. The opera- 
tion is a serious one and often fatal. Recurrence takes place 
in the neighboring tissues in the large majority of those that 
survive the operation. A few recover. 

Treatment. The only treatment is the immediate removal 
of the tumor. 



DISEASES OF THE KIDNEYS AND BLADDER. 459 

CASE 141. Frank N. was the only child of healthy 
parents. He had had much trouble with his digestion be- 
tween his fourth and ninth years and had always been subject 
to bronchitis. He had measles at two years and broke his 
arm when five years old. When ten and one-half years old 
he had pneumonia, followed by empyema. The sinus did 
not close for six months. He was very much pulled down by 
this illness and did not regain his strength until six months 
later. Puffiness of the eyelids had been noticed from time 
to time ever since the closing of the sinus, but no attention 
was paid to it until six months later, when swelling of the feet 
also appeared. At this time he was often unable to put on 
his shoes in the morning and hardly able to open his eyes 
during the early part of the day. His physician, who was 
then called, found that he was passing about one quart of 
urine daily, which was acid in reaction, of a specific gravity of 
1 016 and contained one-eighth per cent of albumin. The 
sediment was not examined. He cut meat and eggs out of 
the boy's diet and advised the ingestion of large amounts of 
water. Under this treatment the edema diminished, but the 
urine continued to contain albumin. During this time he had 
no headache, dizziness, nausea or vomiting and appeared well 
except for the edema of the eyelids. The swelling of the feet 
had returned about a month before he was seen, when twelve 
years old, but had disappeared again during the last week, 
which he had spent in bed on account of an attack of acute 
bronchitis. 

Physical Examination. He was fairly developed and 
nourished and very pale. His face was generally puffy and 
the eyelids were so much swollen that it was difhcult for him 
to open them wide enough to see. The tongue was moist and 
considerably coated. The throat was normal. The cardiac 
impulse was in the fifth space, nine cm. to the left of the 
median line. The left border of dullness corresponded with 
the impulse. The right border was three cm. to the right of 
the median line and the upper border at the third rib. The 
action was regular, the sounds were strong and there were no 
murmurs. The second sounds at the pulmonic and aortic 
areas were of the same intensity. There was a venous hum 



460 CASE HISTORIES IN PEDIATRICS. 

in the neck. The tension in the radial arteries was not per- 
ceptibly increased. The scar of the old operation for empy- 
ema was in the lower right axilla. The lungs were normal, 
except that there were many sibilant and sonorous rales on 
both sides, both in front and behind. The upper border of 
the liver flatness was at the upper border of the sixth rib in 
the nipple line; the lower border was not palpable. The 
spleen was not palpable. There was slight dullness in the 
flanks, which did not change with change of position. There 
was no fluid wave. The abdomen was otherwise normal. 
There was no edema of the extremities or of the external 
genitals. There was no enlargement of the peripheral lymph 
nodes. 

The twenty-four hours amount of urine was thirty-four 
ounces. It was of normal color, acid in reaction, of a specific 
gravity of 1016 and contained at least two per cent of albumin. 
The centrifugalized sediment contained very many casts, 
hyaline, fine granular, coarse granular, epithelial, fatty and 
waxy. It also contained a moderate number of leucocytes 
and small round cells, a few normal and abnormal red blood 
corpuscles, an occasional compound granule cell and much 
free fat. 

Diagnosis. The Bronchitis is merely an incidental com- 
plication. The examination of the urine shows that he has 
nephritis. The duration of the edema, the enlargement of 
the heart and the increase in the intensity of the second sound 
at the aortic area show that it is chronic. The appearance of 
the symptoms coincident with the long-continued discharge 
of pus from the chest suggests that amyloid disease of the 
kidneys is the cause of the trouble. The absence of enlarge- 
ment of the liver and spleen and the large amount of albumin 
and fat in the urine show, however, that this is not the case. 
The age of the child, the edema, the absence of an increase 
in the amount of urine, the large amount of albumin and the 
character of the sediment rule out chronic interstitial ne- 
phritis. The diagnosis is, therefore, by exclusion, Chronic 
Parenchymatous Nephritis. The history, the absence of 
an increase in the amount of urine, the large amount of 
albumin and the presence of waxy casts and fat in the sedi- 



DISEASES OF THE KIDNEYS AND BLADDER 46 1 

ment are, moreover, characteristic of this condition. The 
red blood corpuscles in the sediment show that there is also 
an acute exacerbation of the process. 

Prognosis. The prognosis is hopeless. He will almost 
certainly not live more than a year, probably not but a few 
months, under medical treatment. 

Treatment. The principles of the treatment of acute 
nephritis are described in Case 137. This being a hopeless 
condition, it will not be necessary to limit his diet as closely 
as in the acute form. There is no objection to giving him a 
part of his proteids in the form of meat and eggs, although it 
will be wise to exclude broths. There is not sufficient edema 
to call for the application of heat externally, but it will be 
well to keep his bowels freely open. It is not advisable, in 
spite of the edema, to cut down his liquids enough to make 
him uncomfortable. They should be limited, however, to 
this extent. He ought to stay in bed until over the bronchi- 
tis. There is no reason why he should not then be up and 
about, but he should avoid exposure and fatigue. That is, 
his life and treatment should be regulated so as to make him 
live as long as possible, but his routine should not be so 
rigorous as to make his last days miserable. It is very 
probable that decapsulation of his kidneys (Edebohls' oper- 
ation) will produce an amelioration of his symptoms and 
prolong his life. There is, however, little or no chance 
that it will cure him. The danger of the operation and its 
probable results should be explained to the parents and they 
should be allowed to decide whether they wish to have it 
done or not. 

The treatment of this type of bronchitis is described in 
Case 104. 



462 CASE HISTORIES IN PEDIATRICS. 

CASE 142. Richard P., five and one-half years old, was 
the first child of healthy, normal parents. He had always 
been well. He had never ceased to wet the bed, although he 
had not wet his trousers since he was old enough to wear 
them. He usually wet the bed soon after going to sleep and 
again in the early morning. He slept very heavily. Re- 
moval of his adenoids and circumcision had not diminished 
the frequency of the wetting. He had had no other treatment, 
except that the ingestion of liquids had been somewhat limited 
during the latter part of the day. His appetite and digestion 
were good and his bowels moved regularly. No pin-worms 
had ever been seen. He was not especially nervous. 

Physical Examination. He was well developed and nour- 
ished and of good color. He seemed of normal intelligence 
and did not appear at all neurotic. His tongue was clean, 
his teeth good and his throat normal. The heart, lungs and 
abdomen were normal. The liver and spleen were not pal- 
pable. There was no irritation of the penis and no irritation 
about the anus. The extremities were normal. There was no 
spasm or paralysis. The knee-jerks, cremasteric and ab- 
dominal reflexes were normal. There was no enlargement 
of the peripheral lymph nodes. 

The urine was of normal color, clear, highly acid in reaction, 
of a specific gravity of 1030, and contained neither albumin 
nor sugar. 

Diagnosis. The diagnosis is, of course, Nocturnal Enu- 
resis. It is, moreover, undoubtedly, not organic in origin, 
but of the so-called "functional" or ** essential " type. There 
are no evidences of inflammation or irritation of the rectum, 
penis, urethra or bladder. The only possible reflex cause is, 
then, the highly acid and concentrated urine. It is probable, 
however, that this is merely a temporary condition and not 
the real cause of the trouble. Neither he nor his parents are 
neurotic, his general condition is good and he is not anemic. 
Increased irritability of the spinal centres cannot, therefore, 
be the cause. It must be, then, interference with the normal 
cerebral control of the spinal centres. This interference 
cannot be due to adenoids, as they have been removed. It is, 
in all probability, the result of a combination of somewhat 



DISEASES OF THE KIDNEYS AND BLADDER. 463 

tardy development of the cerebral centres and the depressing 
influence of very deep sleep on their action. 

Prognosis. He is certain to get over it, because as time 
goes on the cerebral centres will develop and be able to control 
the spinal centres, even during deep sleep. It is impossible 
to know how long it will be before this happens, probably, 
however, not under a year. Careful treatment will pre- 
sumably relieve the condition to a certain extent and perhaps 
hasten recovery. 

Treatment. He cannot help wetting the bed when he is 
asleep. Not being responsible for the condition, he ought 
not, therefore, to be punished for it. Appeals to his pride or 
rewards may be of some assistance, but probably will not. 
He should be given water freely, to diminish the concentration 
of the urine, and citrate of potash in doses large enough to 
make the reaction neutral or slightly alkaline. Fifteen grains, 
three or four times daily, will probably be sufficient to do this. 
The water must all be given, however, before 4 p.m., because, 
if given later than this, it will increase the tendency to wet the 
bed by filling up the bladder. He should, for the same reason, 
have as dry a supper as possible. He should pass water just 
before going to bed and should be waked up early in the 
evening to pass it again. He should also be made to pass it 
when his parents go to bed and as soon as he begins to wake 
up in the morning. He should sleep on a hard bed. His 
coverings must be carefully regulated. If he is too warm, he 
will sleep more soundly and be more likely to wet, while, if 
he is cold, he will secrete more urine, which will also cause 
him to wet the bed. It will be well to raise the foot of the 
bed about six inches, as this tends to take the pressure of the 
urine off of the sensitive neck of the bladder. He will be 
less likely to wet the bed if he is kept relatively quiet, both 
physically and mentally, after five in the afternoon. It 
will also be advisable to give him exercises to train him to 
control his bladder. He should be made to pass water every 
ten or fifteen minutes for an hour at some time during the 
day and at another should be made to hold his water as long 
as possible. 

Belladonna is indicated in this instance, because of its 



464 CASE HISTORIES IN PEDIATRICS. 

action in diminishing reflex excitability. He should be 
given five drops of the tincture of belladonna after supper. 
The dose should be increased one drop each night until 
toxic symptoms appear. It should then be diminished two 
drops, and kept at this point for some months. He is in 
good condition and shows no signs of nervous irritability. 
Tonics and nerve stimulants, such as strychnia, are, there- 
fore, not indicated. 



SECTION XI. 
DISEASES OF THE BLOOD. 

CASE 143. Mary J. was seen when twenty- three months 
old. Her mother had died soon after her birth of a cancer 
which she had had during the pregnancy. She had always 
been fed exclusively on modified milk. She had had no ill- 
nesses except several slight digestive upsets when about a 
year old. She took her food well and did not vomit, although 
at times she seemed nauseated. Her bowels moved regularly 
and the movements were normal. She was listless and quiet 
and her temperature was usually a little subnormal. 

Physical Examination. She was well developed and nour- 
ished, but moderately pale. The anterior fontanelle was closed 
and her head was of good shape. She had twelve teeth. Her 
tongue was clean and her mouth and throat normal. There 
was a venous hum in the neck. The heart was normal 
except for a systolic murmur at the pulmonic area, which was 
not transmitted. The lungs were normal. There was a 
slight rosary. The level of the abdomen was that of the 
thorax. The liver was palpable i cm. below the costal border 
in the nipple line. The spleen was not palpable. The ex- 
tremities were normal. There was no spasm or paralysis. 
The knee-jerks were equal and normal. There was no 
enlargement of the peripheral lymph nodes. 

The urine was pale, clear, faintly acid in reaction, of a 
specific gravity of 1,012, and contained neither albumin nor 
sugar. The sediment showed nothing abnormal. 

Blood. 
Hemoglobin, 50% (normal = 70%) 

Red corpuscles, 5,122,000 (normal = 5,500,000 to 6,000,000) 
White corpuscles, 11,300 (normal = 10,000 to 12,000) 

Mononuclears, 31%^ 

Poly nuclear neutrophils, 65% 

Eosinophiles, l% [ 

Mast cells, 3%^ 

465 



(normal) 



466 CASE HISTORIES IN PEDIATRICS. 

The red corpuscles showed some variation in size and shape 
and some achromia, but no nucleated forms. 

Diagnosis. The venous hum in the neck and the systolic 
murmur at the pulmonic area are, of course, merely signs of 
the very evident anemia. The percentage of hemoglobin is 
about seventy per cent of the normal, while the number of 
red corpuscles is about ninety per cent of the normal. The 
morphological changes in the red corpuscles are so slight that 
they are of but little importance. The blood picture is, there- 
fore, that of chlorosis. The diagnosis of chlorosis is for many 
reasons, however, not justified in this instance, in spite of the 
characteristic blood picture. 

In the first place, the percentage of hemoglobin is always 
relatively low in infancy. This is presumably due to the 
fact that the infant normally receives an insufficient supply 
of iron in its food and that the reserve of iron present in the 
liver at birth is not large enough to keep the percentage of 
hemoglobin at the adult standard. The reserve of iron is, 
moreover, often insufficient, and in any event is compara- 
tively easily exhausted. It is seldom sufficient to outlast the 
first year. This relative disproportion between the hemo- 
globin and the number of red corpuscles, when compared 
with the adult standard, is almost always exaggerated in the 
blood diseases of infancy. 

This infant was, on account of her mother's illness during 
the pregnancy, probably born with an insufficient reserve of 
iron. She has never had any food but milk, which does not 
contain enough iron to meet the needs of the normal infant's 
system. Her reserve, being insufficient, was undoubtedly 
exhausted long before the end of the first year, so that for a 
year or more she has been unable to make up for the lack of 
iron in her food and has been falling more and more behind. 
That is, the causes which make the hemoglobin low under 
normal conditions in infancy are much exaggerated in her 
case. The diagnosis of chlorosis is, therefore, not justified 
in this instance. The real condition is a Secondary Anemia, 
due to the long-continued exclusive milk diet. 

Further evidence against the diagnosis of chlorosis in these 
cases is that they occur indifferently in boys and girls, and 



DISEASES OF THE BLOOD. 467 

that they have no pathologic connection with the nervous or 
genital systems. 

Prognosis. The addition of other foods to her diet and the 
administration of iron will improve the condition of the 
blood very rapidly. 

Treatment. Beef juice and egg should be at once added to 
her diet because of the iron which they contain. Starchy foods 
should also be added. She is old enough to digest them and 
needs a more varied diet in order to thrive. The best forms 
of iron for her are the saccharated oxide and ferratin. The 
former may be given in five-grain and the latter in three- 
grain doses, three times daily, after food. 



468 CASE HISTORIES IN PEDIATRICS. 

CASE 144. Alma H., seven months old, was the second 
child of healthy parents. There was no tuberculosis in the 
family and there had been no known exposure to tuber- 
culosis. She was born at full term after a normal labor, 
was normal at birth and weighed ten pounds. She had had 
nothing but the breast and had always done well. The 
outside of the house had been painted just before the onset of 
her illness. Her mother also menstruated for the first time 
just at the time of the onset. Her parents affirmed that she 
was perfectly well and had a good color on April 2. Marked 
pallor was noted the next day. She had had no hemorrhages 
or other symptoms of illness. The pallor became yellowish 
on April 6 and the mucous membranes pale on April 7. 
There had been no increase in the pallor up to April 1 1 , when 
she was seen. The conjunctivae had not been yellow, the 
movements had been dark green in color and the urine had 
not contained bile. She had had no hemorrhages and had 
not been tender. She had taken her food well and had not 
vomited. She had had no fever, but at times had seemed 
chilly and had had cold and blue extremities, but no sweat- 
ing. She had become very quiet, but was not fussy. 

Physical Examination. She was decidedly apathetic. She 
was well developed and nourished, but very pale. The skin 
had a decided yellowish tinge, but the conjunctivae were clear. 
The anterior fontanelle was 2 cm. in diameter and level. 
There was no rigidity of the neck and the head was of good 
shape. The tongue was clean; the mouth, gums and throat 
normal. There were no teeth. There was a slight venous 
hum in the neck. There was no rosary. The heart was nor- 
mal except for a slight systolic murmur at the pulmonic 
area, which was not transmitted. The lungs and abdomen 
were normal. The liver was palpable 3 cm. below the costal 
border in the nipple line. The spleen was not palpable. 
There was no tenderness or swelling of the extremities except 
a little puffiness of the feet. There was also a little puffiness 
about the eyes. There was no spasm or paralysis. The knee- 
jerks were equal and normal. There was no enlargement of 
the peripheral lymph nodes. There were no hemorrhages 
into the skin and no eruption or scars of old eruptions. 



diseases of the blood. 469 

Blood. 

Hemoglobin, 20% (normal = 70%) 

Red corpuscles, 1,492,000 (normal = 5,500,000 to 6,000,000) 

White corpuscles, 11,000 (normal = 10,000 to 14,000) 

Small mononuclears, 68% (normal = 40% to 50%) 

Large mononuclears, 7% (normal = 10%) 

Polynuclear neutrophiles, 21% (normal = 35% to 45%) 

Eosinophiles, 4% (normal = l% to 5%) 

The red corpuscles showed marked variation in size, the 
tendency being toward large forms. There was slight 
poikilocytosis and moderate polychromatophilia, but no 
stippling. Three normoblasts were seen in counting one 
hundred white cells. Some of the white cells were very 
large, looking like large cells from the bone marrow, and were 
throwing off blood plates. There was a large increase in the 
number of blood plates. No malarial organisms were seen. 

Diagnosis. It is very hard to believe that, in the absence 
of hemorrhages, the anemia developed as rapidly as the par- 
ents affirm. The blood picture is that of a more chronic con- 
dition, and it seems probable, therefore, that the parents did 
not notice the condition until it was fully developed. It is 
also difficult to believe that the painting of the house or the 
mother's menstruation had anything to do with its develop- 
ment. The absence of stippling of the red cells is much against 
lead poisoning. Menstruation sometimes causes disturbances 
of digestion, but not anemia. It is more probable that the 
breast milk, while suitable in other ways, was deficient in 
iron, and that after the reserve supply in the liver was 
exhausted the anemia developed gradually. Scurvy can be 
ruled out as a cause on the absence of tenderness and swelling 
of the extremities and of hemorrhages. Malaria can be 
excluded on the absence of plasmodia in the blood. 

The morphological changes in the red corpuscles, the 
predominance of the large over the small forms of red cells, 
the presence of nucleated cells and the large percentage of 
mononuclear leucocytes would in the adult point strongly 
toward pernicious anemia. The tendency common to all the 
anemias of infancy to revert to a younger type of blood and 
the normal preponderance of mononuclear leucocytes and of 



470 CASE HISTORIES IN PEDIATRICS. 

greater variation in their size make these points of practically 
no importance in the diagnosis of pernicious anemia in in- 
fancy. In all probability, moreover, pernicious anemia does 
not occur at this age. The large number of blood plates 
present in this instance would exclude it, even in an adult. 

Acute lymphatic leukemia in an aleukemic stage is sug- 
gested to a certain extent by the changes in the red cells and 
the comparatively large proportion of mononuclear leuco- 
cytes. The absence of enlargement of the spleen and lymph 
nodes and the age are much against it. The slight signifi- 
cance of the changes in the red cells and of the excess 
of mononuclear leucocytes has already been explained. 
The large number of blood plates practically excludes 
leukemia. 

There is nothing about the blood picture which is in any 
way inconsistent with a secondary anemia in infancy. A 
diagnosis of Secondary Anemia is, therefore, justified, a 
possible cause being a deficiency of iron in the mother's milk. 

Prognosis. The condition of the blood will undoubtedly 
improve rapidly if iron is given. 

Treatment. The baby has done so well in every other way 
on its mother's milk that it is unwise to wean it, since any 
deficiency of iron in the milk can be very easily remedied by 
the administration of iron. This may be given by mouth in 
the form of the saccharated oxide or of ferratin. When 
the anemia is as marked as it is in this instance it is better, 
however, to give it subcutaneously, because the improvement 
begins so much sooner and is so much more rapid than when 
it is given in the ordinary way. The best form of iron for 
subcutaneous use is the aqueous solution of the citrate. 
This can be put up in pearls and sterilized, and when pre- 
pared in this way remains sterile indefinitely. It is not irri- 
tating. If given subcutaneously, the injection rarely causes 
much pain, but, if given intramuscularly, it is often very 
painful and sometimes causes slight symptoms of shock. It 
must be given with a glass syringe with asbestos packing and 
a platinum needle. The syringe and needle must, of course, 
be sterilized. The dose for this infant is three quarters of a 
grain, every other day. 



DISEASES OF THE BLOOD. 47 1 

CASE 145. Jennie R., the daughter of healthy parents, 
was one of twins. The other had always been well. Another 
child was well, while a fourth had died in infancy of "sum- 
mer complaint." She was nursed for five weeks, after which 
she was given modified milk, prepared at a laboratory, for 
three weeks. She had been fed since this time on a modified 
milk, prepared at home. The mixture, which was a weak 
one, had not been changed, however, for seven months. 
During this time she had had no disturbance of digestion, 
but had gained very slowly. She had a slight attack of diar- 
rhea when nine months old, which yielded quickly to treat- 
ment and was followed by constipation. Since then she had 
taken a stronger modification of milk and had had no dis- 
turbance of digestion. She was seen when ten months old 
because she was not thriving. 

Physical Examination. She was fairly developed and nour- 
ished. There was moderate pallor of the skin and mucous 
membranes. The anterior fontanelle was three cm. in 
diameter and level. The head was flattened on top and be- 
hind, but there was no craniotabes. There were two teeth. 
She sat alone feebly, but with the spine straight. There was 
a marked rosary. There was slight retraction of the chest at 
the insertion of the diaphragm. The heart and lungs were 
normal. The abdomen was distended but otherwise normal, 
except for a slight umbilical hernia. The upper border of the 
liver flatness was at the upper border of the fifth rib ; the lower 
border of the liver was palpable three cm. below the costal 
border in the nipple line. The spleen was felt running out 
from beneath the costal border in the left anterior axillary 
line to the right of the umbilicus, then downward and back- 
ward to the left anterior superior spine and backward into 
the loin. The surface was smooth, the consistency firm. 
The notch was felt distinctly in the left nipple line, midway 
between the costal border and the navel. The extremities 
were normal except for a moderate enlargement of the epiph- 
yses at the wrists. There was a slight general enlargement 
of the peripheral lymph nodes. She weighed ten pounds and 
two ounces. 



472 CASE HISTORIES IN PEDIATRICS. 

The urine was pale, acid, of a specific gravity of 1015 and 
contained no albumin or sugar. 

Blood. 

Hemoglobin, 40% (normal = 70%) 

Red corpuscles, 4,000,000 (normal = 5,500,000 to 6,000,000) 
White corpuscles, 18,750 (normal = 10,000 to 12,000) 

Small mononuclears, 344% (normal = 40% to 50%) 

Large mononuclears, 12.6% (normal = 10%) 

Polynuclear neutrophiles, 51% (normal = 35% to 45%) 
Eosinophiles, .2% (normal = 1% to 5%) 

Myelocytes, 1.8% 

jThe red corpuscles showed marked variation in size, shape 
and staining reaction. There was no tendency to large forms, 
but a slight tendency to oval forms. Sixteen normoblasts 
and nine megaloblasts were seen in counting five hundred 
white corpuscles. 

Diagnosis. The flattening of the head, the rosary, the 
retraction of the chest at the insertion of the diaphragm and 
the enlargement of the epiphyses at the wrists are signs of 
rickets, as is probably the delay in the eruption of the teeth. 
The general enlargement of the peripheral lymph nodes is 
merely a manifestation of a disturbance of the nutrition. 
The pallor and the changes in the blood show that she has an 
anemia. The presence of myelocytes, megaloblasts and such 
marked morphological changes in the red corpuscles would 
suggest, in an adult, pernicious anemia. In an infant, how- 
ever, they are merely evidences of the tendency of the blood 
to revert to a younger type. The greater relative diminution 
in the percentage of hemoglobin than in the number of red 
corpuscles, 57% against about 70%, is characteristic of 
secondary anemia in infancy. (See Case 143.) The leucocy- 
tosis may or may not be directly connected with the anemia. 
It is not at all uncommon in secondary anemia in infancy, 
however, and is of no especial significance. The blood changes 
are, therefore, entirely consistent with those of secondary 
anemia. 

There is, in addition, a marked enlargement of the spleen. 
What is the connection, if any, between the rickets, the 



DISEASES OF THE BLOOD. 473 

anemia and the enlargement of the spleen? Is any one of 
them the cause of the others, or are they all manifestations of 
some common cause? It is certain that the anemia and the 
splenic tumor could not have caused the rickets. Could the 
rickets have caused the anemia and splenic tumor? While 
it is conceivable that they might have, the chances are very 
much against it, because the study of large series of cases 
shows that there is no connection whatever between the sever- 
ity of the rickets and that of the anemia and the size of the 
spleen, many babies showing marked rickets and no anemia, 
others mild rickets and severe anemia, and so on. In the 
same way, marked enlargement of the spleen is often found 
in connection with mild rickets and no enlargement of the 
spleen in some of the most marked cases. The study of other 
series of cases shows that there is no connection between the 
size of the spleen and the changes in the blood, very marked 
changes being present in the blood when the spleen is not 
enlarged, very slight when the spleen is much enlarged, and 
so on. It seems reasonable to conclude, therefore, that the 
rickets, the anemia and the enlargement of the spleen are all 
manifestations of some common cause. This cause is not 
hard to find. It is undoubtedly the disturbance of nutrition 
due to the prolonged use of too weak a food. 

The combination of marked changes in the blood and 
splenic tumor, as is present in this instance, has often been set 
aside as a special disease and described under various names, 
the most common of which is anemia infantum pseudoleuke- 
mica. The combination is always, however, as in this in- 
stance, accidental, and does not constitute a specific disease. 
The characteristics of the anemia are, as already shown, 
those of secondary anemia in infancy, and the enlargement 
of the spleen is merely a manifestation of the same disturb- 
ance of nutrition which is responsible for the anemia. It is 
better to speak of it, therefore, as Secondary Anemia with 
Splenic Tumor. 

Prognosis. The prognosis is perfectly good. When the 
underlying disturbance of nutrition is corrected the spleen 
will diminish rapidly in size and the anemia will quickly 
improve. The spleen will probably not be palpable after 



474 CASE HISTORIES IN PEDIATRICS. 

two or three months and the blood will be normal at least as 
soon. 

Treatment. The treatment is regulation of the diet to 
correct the disturbance of nutrition. The administration of 
iron will also hasten the return of the blood to normal. The 
following mixture is a suitable one for her: 

Fat, 4% 

Sugar, 7% 

Proteids, 2.50% 

Starch, 0.75% 

There is no indication for the addition of an alkali. Six 
feedings of five ounces will much more than supply the 
caloric needs indicated by her weight, but will probably be 
no more than are required when her age and surface area 
are taken into consideration. 

One or two tablespoonfuls of beef juice, once daily, given 
at the same time as one of her feedings, will aid in supplying 
the needed iron. It will be wiser, however, to give iron in 
addition. It may be given as the saccharated oxide or 
in the form of ferratin. The dose of the former is three 
grains; that of the latter, two grains, three times daily. 



DISEASES OF THE BLOOD. 475 

CASE 146. George S., eight years old, was the child of 
healthy parents. Three brothers were well. One child had 
died of tubercular meningitis and another was born dead at 
full term. There had been no miscarriages. There was no 
history of hemorrhages in either family, except that the 
daughter of a maternal aunt, when eight years old, had bled 
steadily for twelve hours after the extraction of a tooth. 
She had had, however, no other hemorrhages before or since. 
His mother had had what was called chlorosis at the time of 
puberty. He had never been outside of eastern Massachu- 
setts. 

He was born at full term, after a normal labor, and weighed 
five and one-half pounds. He was nursed for five months and 
did well. He had whooping-cough when six months old, 
pneumonia at one year and measles at one and one-half years. 
He had been well since then, but had always been a little pale. 
Five months before he was seen he complained of headache 
without obvious cause, and the next morning had a severe 
nosebleed which was finally stopped, after two hours, by 
plugging the anterior nares. He had been somewhat paler 
since the nosebleed but was considered well. He always had 
more or less "black and blue" spots on him, however, some 
of which were apparently not due to injuries. A week before 
he was seen he became listless and much paler. There had 
been a little bleeding from the gums during the last two days. 
His appetite was good. He had no symptoms of indigestion, 
his bowels moved regularly and the stools did not contain 
blood. He had no dizziness, headache or dyspnea. He was 
admitted to the Children's Hospital, August 16. 

Physical Examination. He was poorly developed and 
nourished and somewhat listless. There was marked pallor 
of the skin and mucous membranes. His teeth were poor, 
but the gums were healthy and there was no bleeding from 
them. The area of cardiac dullness was normal and the 
action regular. The first sound was somewhat feeble and 
there was a systolic murmur over the whole precordia. There 
was a venous hum in the neck. The lungs and abdomen were 
normal. The upper border of the liver flatness was at the 
sixth rib in the nipple line ; the lower border was just palpable 



476 CASE HISTORIES IN PEDIATRICS. 

below the costal border in the same line. The spleen was not 
palpable. The extremities were normal. There was no 
enlargement of the peripheral lymph nodes. There were a 
few ecchymoses on the legs and thighs. The temperature 
was normal. 

The urine was clear, acid in reaction, of a specific gravity of 
1 01 5 and contained neither albumin nor sugar. The sedi- 
ment showed nothing abnormal. 

The stools showed that there was no disturbance of the 
digestion of any of the food elements. They contained some 
mucus but no blood or pus. All foods containing blood were 
stopped for forty-eight hours. The stools were then ex- 
amined by the guiac test and no blood found. 

A skin tuberculin test was negative. 

Blood. 

Hemoglobin i8% (Sahli) 

Red corpuscles 672,000 

White corpuscles, 8,000 

Small mononuclears, 37% 
Large mononuclear and transition forms, 10% 

Polynuclear neutrophils, 49% 

Eosinophiles, 4% 

There was some achromia and slight poikilocytosis and 
stippling of the red cells. Many of the red cells were as large 
as the leucocytes. No nucleated red cells were seen and no 
abnormal forms of white cells. Many of the white cells were 
broken down. The coagulation time was two and one-half 
minutes. 

He was kept under observation at the hospital and at the 
Convalescent Home until Nov. i. During this time he had 
no hemorrhages and gained in weight. He said that he felt 
well and while at the Convalescent Home was able to play 
with the other children. Repeated examinations of the 
stools failed to find either parasites or their ova and no Plas- 
modia were found in the blood. He was unable to take 
arsenic, even in minute doses, without showing toxic symp- 
toms. He apparently did as well, or better, without iron 
than with it, whether it was given by mouth or under the 
skin. He was still pale and waxy. The murmur in the 



DISEASES OF THE BLOOD. 477 

heart and the venous hum were still present. The liver and 
spleen were not palpable. There was no enlargement of the 
peripheral lymph nodes. 

Blood. 

Hemoglobin, 20% (Sahli) 

Red corpuscles, 790,000 

White corpuscles, ' 3,800 

Small mononuclears, 41% 

Large mononuclears and transition forms, 2% 

Polynuclear neutrophiles, 57% 

There was slight polychromatophilia and considerable macro- 
cytosis, but very little poikilocytosis. There was no stip- 
pling of the red cells and no nucleated cells were seen. There 
were no abnormal forms of white cells. The blood platelets 
numbered 320,000. The coagulation time was two and one- 
half minutes. The clot was normal. 

Diagnosis. The history of the bleeding in his cousin and 
of the severe nosebleed and ''black and blue spots" in the 
past, together with the recent oozing from the gums, suggest 
hemophilia. When it is remembered that the cousin is a 
girl, that she had had no other hemorrhages and that he has 
had but one severe hemorrhage, this history is, however, 
much less suggestive. The normal coagulation time of the 
blood and the normal character of the clot, are, moreover, 
sufficient to exclude hemophilia. The characteristics of the 
blood are not those of leukemia. An aleukemic stage would 
hardly last so long and there is no excess of lymphocytes. 
There is, moreover, no enlargement of the spleen or lymph 
nodes. The fact that he has never been outside of eastern 
Massachusetts, together with the absence of parasites and 
their ova in the stools at repeated examinations, rule out 
anemia from the hookworm or other intestinal parasites. 
The absence of blood in the stools by the guiac test shows 
that there is no concealed intestinal hemorrhage. There is 
nothing in his history or physical examination to account for 
the anemia. It did not improve, moreover, when he was in 
the country and having good food. The anemia is more 
marked than is usual in secondary anemia without obvious 
cause, the color index is slightly above normal, there is a 



478 CASE HISTORIES IN PEDIATRICS. 

considerable macrocytosis and there is no leucocytosis. It 
is almost certain, therefore, that, in spite of the normal 
number of blood platelets and the absence of a relative lym- 
phocytosis, the anemia is of the primary rather than of the 
secondary type. There are usually, however, marked mor- 
phologic changes in the red corpuscles and many normoblasts 
and megaloblasts in pernicious anemia, which is not the case 
in this instance. The absence of morphologic changes in the 
red cells and of nucleated cells is characteristic of the blood 
picture in the aplastic type of this disease, so that it cannot 
be excluded on this account. In this type, however, there is 
usually little or no macrocytosis and a marked diminution in 
the polynuclear neutrophiles. It is evident, therefore, that 
the blood picture does not exactly correspond to that of any 
of the types of anemia. Taking everything into considera- 
tion, however, a probable diagnosis of Pernicious Anemia 
of the Aplastic Type seems justified. 

Prognosis. If the diagnosis is correct, the prognosis is 
hopeless. He will probably not live many months. 

Treatment. There is very little to be done for him medic- 
inally. He cannot take arsenic and does better without 
iron than with it. The most that can be done, therefore, is 
to take the best possible care of him, to feed him as well as 
possible, to keep him quiet and to give him the maximum 
amount of fresh air and sunlight. 



DISEASES OF THE BLOOD. 479 

CASE 147. Lester J. had always been well, but a little 
delicate. A slight enlargement of the cervical lymph nodes 
was noticed about the first of June. It had not increased 
materially up to July lo, when he came down with scarlet 
fever. The scarlet fever was of a very mild type and he was 
out of quarantine August 13. The swelling in the neck 
increased very rapidly after the onset of the scarlet fever. 
The temperature rose again August 20 and ran between 
103° F. and 104'' F. Enlargement of the spleen was noticed 
for the first time August 23, but may have been present be- 
fore, as it had not been looked for until that time. The size 
of the liver was not investigated. The mouth and throat 
became sore August 26, and several spots of membrane ap- 
peared in the mouth. A culture showed no diphtheria bacilli. 
He had had no disturbance of digestion, looseness of the 
bowels or hemorrhages, and had not lost weight, strength or 
color. He had not seemed seriously sick until a few days 
before he was seen in consultation, August 2"], when six 
years old. 

Physical Examination. He was small, slight and flabby, 
but not very pale. There was an ulcerated area, the size of a 
dime, covered with false membrane, on the left side of the 
mouth. The whole throat was slightly reddened. The tonsils 
were moderately enlarged. The tongue was somewhat dry 
and slightly coated. There was no nasal discharge. There 
was a large mass of discrete, non-tender lymph nodes in the 
left side of the neck, which filled up the whole neck, extend- 
ing forward even with the chin and downv/ard to the clavicle. 
There were numerous small lymph nodes in the right side of 
the neck. There was no dullness under the manubrium or 
in the middle of the back, and the bronchial voice sounds did 
not extend below the seventh cervical spine, showing that there 
was no considerable enlargement of the bronchial lymph 
nodes. There was no venous hum in the neck. The heart, 
lungs and abdomen were normal. The upper border of the 
liver flatness was at the upper border of the fifth rib (normal 
is in the fifth space). The lower border was palpable, running 
from just above the right anterior superior spine, through a 
point two thirds the distance from the ensiform to the navel. 



480 CASE HISTORIES IN PEDIATRICS. 

to the left costal border in the nipple line. The surface of the 
liver was hard and smooth, the edge rounded. The spleen 
was palpable, running out from the costal border between the 
left nipple and anterior axillary lines, downward and for- 
ward almost to the median line, backward to the left anterior 
superior spine and upward into the flank. The surface was 
smooth, the consistency hard, the edge rounded, the notch 
distinct. The extremities were normal. There was no spasm 
or paralysis. The knee-jerks were equal and normal. There 
were numerous lymph nodes, the size of marbles, in the axillae 
and groins, and one, the size of a walnut, on the occiput. 
The epitrochlear lymph nodes were not palpable. The 
mouth temperature was 104° F. 

The urine was high in color, extremely acid in reaction, and 
of a specific gravity of 1,032. It was loaded with urates, but 
contained no albumin or sugar. The sediment showed a few 
small round cells, but no casts. 

Blood. 

Hemoglobin, 70% 

Red corpuscles, 3,520,000 

White corpuscles, 128,000 

Mononuclears (almost entirely lymphocytes), 99-2% 

Polynuclear neutrophils, .6% 

Myelocytes, .2% 

There was a very little variation in the size of the red 
corpuscles, but none in their shape or color. No nucleated 
cells were seen while counting five hundred white corpuscles. 

Diagnosis. Without the examination of the blood the 
diagnosis would lie between lymphatic leukemia and Hodg- 
kin's disease. The enlargement of the liver and the ulceration 
of the mouth would, however, make lymphatic leukemia the 
more probable. The examination of the blood proves con- 
clusively that the trouble is Lymphatic Leukemia. The 
enlargement of the lymph nodes preceded the attack of 
scarlet fever by six weeks. It is almost certain, therefore, 
that this was merely a coincidence and that it played no part 
in the etiology of the leukemia. 

Prognosis. The prognosis is absolutely hopeless. He will 
probably not live more than one or two weeks. 



DISEASES OF THE BLOOD. 48 1 

Treatment. There is little or nothing to be expected from 
treatment. Arsenic and iron may be tried, however, with 
the hope that they may alleviate the condition and perhaps 
prolong life. The arsenic is best given in the form of Fowler's 
solution. It will be well to begin with three drops, three 
times a day, increasing the dose one drop daily until the 
physiological hmit is reached. Other treatment must be 
symptomatic. 

It is possible that temporary improvement may be ob- 
tained by the use of benzol. The proper dose for him is 
three or four drops in a teaspoonful of olive oil four times 
daily. If he is given benzol, great care must be taken not 
to give him too much. The blood must be examined daily 
and the drug stopped when the white count has fallen to 
50,000. 



482 CASE HISTORIES IN PEDIATRICS. 

CASE 148. Mary C, three years old, was the only child of 
healthy parents. There had been no deaths or miscarriages. 
She was bom at full term after a normal labor, was normal 
at birth and weighed eight pounds. She was nursed for 
seven months and did very well. Since then she had taken 
milk well, but it had been very hard to induce her to take 
other food. She had, nevertheless, been very well. 

Seven weeks before she was seen in consultation she began 
to seem a little out of sorts and to lose color. The chief 
symptom had been anorexia and the greatest difficulty had 
been experienced in getting her to take anything, even milk. 
She had vomited occasionally, probably as the result of the 
forcing of food rather than of indigestion. There had been 
a tendency to constipation, which had been easily relieved 
by castoria. The movements had been well digested. Her 
only complaint was of being tired. She did not want to play 
with other children, but preferred to keep quiet or lie down. 
She had not lost weight but had steadily lost color. Purpuric 
spots had appeared on the legs a week previously. She had 
slept poorly and perspired freely. She had had no fever. 

Physical Examination. She was well developed and nour- 
ished, but very pale. Her flesh was firm. There was no 
edema. The tongue was clean, the mouth and throat normal. 
There was a venous hum in the neck. The heart was normal, 
except for a slight systolic murmur at the pulmonic area, 
which was not transmitted. The lungs were normal. The 
liver and spleen were not palpable. The extremities were 
normal. There was no spasm or paralysis. The knee-jerks 
were equal and normal. There was no enlargement of the 
peripheral lymph nodes. There were a dozen or more pur- 
puric spots, varying in size from that of a split pea to that of 
a dime, scattered over the arms and legs, there being more 
on the legs than on the arms. 

Blood. 



Hemoglobin, 


25% 


Red corpuscles. 


2,560,000 


White corpuscles. 


15400 


Lymphocytes, 


99% 


Polynuclear neutrophiles, 


1% 



DISEASES OF THE BLOOD. 483 

There was a little variation in the size and shape of the 
red corpuscles, but most of them were of normal size. There 
was moderate achromia, but no polychromatophilia. There 
was no stippling. One normoblast was seen for each one 
hundred leucocytes. No plasmodia or blood plates were 
seen. 

Diagnosis. The diagnosis lies between a rather severe 
anemia, secondary to an insufficient or improperly balanced 
diet over a long period, with lymphocytosis, and lymphatic 
leukemia in an aleukemic stage. The symptomatology is 
consistent with either diagnosis. The diminution in the 
hemoglobin and in the number of the red corpuscles, as well 
as the morphological changes in them, are consistent with 
either condition. A percentage of lymphocytes as high as 
ninety-nine per cent is practically unheard of outside of 
lymphatic leukemia and is of far more importance in differ- 
ential diagnosis than the comparatively slight increase in the 
total number of the white cells, because the number of white 
cells is often for a time but little increased in lymphatic leu- 
kemia. The absence of blood plates is of itself, moreover, 
sufficient to turn the scale in favor of leukemia, in which the 
blood plates are markedly diminished, while in secondary 
anemia they are normal or increased in number. The lymph 
nodes and spleen are usually, but not always, enlarged in 
lymphatic leukemia. The absence of such enlargement in 
this instance does not, therefore, rule it out. The diagnosis 
is, therefore, Lymphatic Leukemia. 

Prognosis. The prognosis is absolutely bad. She will 
probably not live more than one or two months. 

Treatment. She must, if possible, be made to take a more 
varied diet. If she will not take sufficient food, it must be 
given through a stomach tube, passed through the mouth. 
There is little to be expected from medicinal treatment. 
Arsenic and iron should be tried, however, with the hope that 
they may alleviate the condition and perhaps prolong life. 
The arsenic is best given in the form of Fowler's solution. It 
will be well to begin with two drops, three times daily, 
increasing the dose one drop daily until the physiological 
limit is reached. Other treatment must be symptomatic. 



484 CASE HISTORIES IN PEDIATRICS. 

CASE 149. Carl G. was the only child of healthy parents 
and was born at full term. His mother had had one mis- 
carriage at six months, probably as the result of albuminuria. 
He lived on a farm in the country and had always drunk the 
unsterilized milk from a herd of cows which had for many 
years been infected with tuberculosis. He had had measles 
and chicken-pox as a baby and an abscess in the neck at two 
years, which was opened and healed well. 

He began to be out of sorts about the first of January, 
when six and one-half years old. There were no very definite 
symptoms, however, so that a physician was not called until 
about the middle of March. He found that the boy was 
running an irregular temperature, which at times went as 
high as 103.5° F-j ^^^ that he had an enlarged liver and a 
very large spleen. The urine showed nothing abnormal. 
The leucocytes numbered 6,000. Typhoid fever was suspected, 
but a Widal test was negative. He then improved for a 
time in every way and probably had little or no fever, although 
his temperature was not taken. He was up and about, played 
out of doors and seemed much like himself, except that he 
was easily tired. 

The fever returned about the middle of August. The tem- 
perature was very irregular, most of the time being normal 
or subnormal, but reaching 103° F. or 103.5° F. for a time 
almost every day. Malaria was suspected, although there 
were no chills or sweating. Several examinations of the fresh 
blood failed, however, to show any plasmodia, and there was 
no change in the temperature when quinine was given. 
There had been no change in the size of the liver and spleen. 
The urine showed nothing abnormal. The red corpuscles 
numbered 3,700,000 and the white corpuscles, 6,000. He 
had lost some color. His appetite and digestion had been 
good throughout and he had not lost weight. He had had 
no cough, but several nosebleeds, one of them very severe. 
He was seen in consultation, August 29, when a little more 
than seven years old. 

Physical Examination. He was fairly developed and 
nourished, but moderately pale. He did not look especially 
sick. His tongue was clean and moist, his teeth poor. The 



DISEASES OF THE BLOOD. 4^5 

nose and throat were normal. There was no venous hum in 
the neck. The heart and lungs were normal. The abdomen 
was considerably enlarged, but there were no evidences of 
fluid and no masses were felt. The superficial abdominal 
veins w^ere not enlarged. The upper border of the liver 
flatness was at the upper border of the fifth rib in the nipple 
line (normal is in fifth space) and at the upper border of 
the ninth rib in the scapular line (normal is at the tenth 
rib). The lower border of the liver was palpable, running 
out from the right flank, 4 cm. below the costal border in 
the right anterior axillary line, through a point two thirds 
the distance from the tip of the ensiform to the navel, and 
under the costal border in the left nipple line. The liver was 
not tender, its surface was smooth, its edge sharp. The 
spleen was palpable, running out from beneath the costal 
border in the left nipple line, downward and inward nearly 
to the navel, downward and outward to below the level of 
the left anterior superior spine, then backward into the 
flank, which it filled. It was firm, smooth and not tender. 
The edge was somewhat rounded, the notch distinct. The 
extremities were normal. There was no spasm or paralysis. 
The knee-jerks were equal and normal. There was no 
enlargement of the peripheral lymph nodes and no evidence 
of enlargement of the tracheo-bronchial lymph nodes. There 
was no edema. There was no eruption and no scars of old 
eruptions. 

The urine was normal in color, acid in reaction, of a specific 
gravity of 1,020, and contained neither albumin nor sugar. 
The sediment showed nothing abnormal. 

Blood. 

Hemoglobin, 90% 

Red corpuscles, 3,520,000 

White corpuscles, 5, 700 

Mononuclears (the majority small), 60.0% 

Polynuclear neutrophiles, 38.7% 

Myelocytes, 1.3% 

The red corpuscles showed no changes in size, shape or 
coloring, and no nucleated cells or plasmodia were seen. 
Diagnosis. The diagnosis lies between lymphatic leu- 



486 CASE HISTORIES IN PEDIATRICS. 

kemia in an aleukemic stage, Hodgkin*s disease and that very 
indefinite class of cases known as splenic anemia or anemia 
with splenic tumor. Tuberculosis, which is suggested by 
the prolonged use of milk from a tuberculous herd, can be 
excluded by the absence of signs of tuberculosis elsewhere, 
the slight impairment of the general condition after six 
months, the fact that the liver and spleen are apparently 
alone involved and that the enlargement of these organs is 
regular. A tuberculin test would not be of much assistance. 
If negative, it would, of course, exclude tuberculosis, but, if 
positive, it would not prove that the enlargement of the liver 
and spleen and the fever are tubercular in origin. Syphilis 
can be ruled out on the good family history, the previous 
good health, the fever and the absence of all other signs of 
syphilis in the past or present. Cirrhosis of the liver is 
rendered very improbable by the absence of cause, ascites, 
jaundice and enlargement of the superficial abdominal veins, 
the fever and the relatively great enlargement of the spleen. 

Lymphatic leukemia in an aleukemic stage can be practi- 
cally eliminated on the duration of the illness, the low white 
count on several occasions (the aleukemic stage usually being 
a short one), the absence of morphological changes in the 
red cells and the marked enlargement of the liver and spleen 
without enlargement of the lymph nodes. 

The fever, the condition of the blood, the enlargement of 
the liver and spleen and the relatively slight impairment of 
the nutrition are all consistent with Hodgkin's disease. It 
is almost unheard of, however, to have so much enlargement 
of the liver and spleen without enlargement of either the 
superficial or deep lymph nodes. Hodgkin's disease can, 
therefore, be excluded. 

The most probable diagnosis is, therefore, splenic anemia, 
or better. Anemia with Splenic Tumor. This is, however, 
not a very satisfactory diagnosis because it does not describe 
a definite pathological entity, but is merely a term applied 
to a group of cases in which there is enlargement of the spleen 
and anemia, but of which the pathology and etiology are 
very varied. It is at present, however, impossible to classify 
them any more accurately. 



DISEASES OF THE BLOOD. 487 

Prognosis. The prognosis is very uncertain. He may 
gradually improve and grow up with a large liver and spleen, 
which do not cause any symptoms or inconvenience, or they 
may both finally return to their normal size. He may, on 
the other hand, fail rapidly and die in a few months or live 
on for some years and then die. The chances are that he 
will not live more than a year. 

Treatment. The treatment must, in the main, be hygienic 
and symptomatic. It will be well to try arsenic thoroughly. 
It is best given in the form of Fowler's solution. It will be 
well to begin with three drops, three times a day, increasing 
the dose one drop daily until the physiological limit is reached. 
It should then be continued, in doses somewhat below the 
physiological limit, for several months. If he does not im- 
prove, or continues to fail, splenectomy ought to be consid- 
ered, because, while it is a serious operation and if successful 
does not always relieve the symptoms, it sometimes results 
in a cure. 



488 CASE HISTORIES IN PEDIATRICS. 

CASE 150. William S. was the only child of healthy 
parents. There had been no deaths or miscarriages. There 
was no history of tuberculosis in either family and there had 
been no known exposure to it. He was born at full term, was 
normal at birth, was nursed for nine months and had always 
been perfectly well. A small gland was noticed in the left 
side of the neck in the latter part of January. Another 
gland was noticed on the right side about two weeks later. 
He also lost a little weight and color and his digestion was 
not quite as good as usual. The glands increased in size, 
so that by the first of March they were as large as pigeons' 
eggs. A skin tuberculin test at that time was negative. He 
was then given malt extract and his diet regulated. His 
general condition improved rapidly, but there was no diminu- 
tion in the size of the glands. He passed into the hands of 
another physician about the middle of April. This physician 
prescribed the syrup of the iodide of iron, which he had taken 
continuously since that time. The glands began to enlarge 
again, however, and had continued to increase steadily in 
size. Enlarged glands were discovered in the groins and 
axillae about the middle of July. His mother did not know 
whether they had grown larger since then or not. His tem- 
perature had never been taken, but his mother thought that 
he had been a little feverish at night. His appetite and 
digestion were good and he had not lost weight or color. His 
neck had seemed a little tender during the past week, but 
was not painful. He was seen in consultation, September 13, 
when three years old. 

Physical Examination. He was well developed and nour- 
ished and of fair color. The whole of both sides of the neck 
was filled up with a hard, non-tender mass, which extended 
well backward and so far forward that the chin was hardly 
distinguishable. The swelling ran up behind the ears, but 
not in front of them. Discrete glands could be made out 
in some places, but in others the surface was smooth. There 
was no heat or redness. A chain of glands, varying in size 
from that of a marble to that of a robin's egg, could be felt 
running down behind the clavicles. The pupils were equal 
and reacted to light, The tongue was clean, the teeth good 



DISEASES OF THE BLOOD. 489 

and the throat normal. He kept his mouth shut and there 
was no nasal discharge. There were several glands, the size 
of large beans, in each axilla and the epitrochlear glands were 
as large as peas. There was no dullness under the sternum, 
the respiratory sound was the same on both sides and the 
bronchial voice did not extend downward below the cervical 
spines. The heart and lungs were normal. No enlarged 
glands were found in the abdomen. The upper border of 
the liver flatness was at the upper border of the fifth rib 
in the nipple line. The lower border was palpable six cm. 
below the costal border in the same line. Its surface was 
smooth. The spleen was just palpable. There were nu- 
merous glands, varying in size from that of a pea to that of a 
robin's egg, in both groins. The extremities were normal. 
There was no spasm or paralysis. The knee-jerks were equal 
and normal. There were no mucous patches or rhagades. 
There was no eruption and there were no scars of former 
eruptions. 

Blood. 

Hemoglobin, 75% 

Red corpuscles, 4,500,000 

White corpuscles, 24,800 

Mononuclears, 19% 

Polynuclear neutrophiles, 81% 

The red corpuscles were normal in every way and no ab- 
normal forms of the white cells were seen. 

Diagnosis. The bilateral enlargement of the glands in the 
neck and the general distribution of the glandular enlarge- 
ment, as well as the enlargement of the liver and spleen, are 
strong evidence against tuberculosis as the cause of the 
adenitis, while the absence of a history of tuberculosis does 
not count in any way against it. It is excluded by the 
negative tuberculin test. There is nothing in the history to 
suggest syphilis and there are no physical signs of syphilis 
either at present or in the past. Enlargement of the lymph 
nodes to this extent from syphilis is, moreover, very unusual, 
especially without other marked signs of the disease. Syphi- 
lis can, therefore, be excluded. Leukemia can be excluded 
on the results of the examination of the blood. It is more 



490 CASE HISTORIES IN PEDIATRICS. 

difficult to rule out lymphosarcoma. The chief points against 
it are the good general condition after nine months, the 
absence of involvement of the adjacent structures, the 
absence of enlargement of the tracheo-bronchial lymph nodes 
after so many months and, more than all, the fact that the 
whole picture is so absolutely characteristic of Pseudo- 
leukemia or Hodgkin's Disease. The appearance of the 
enlargement in the cervical glands first, the general distribu- 
tion of the adenitis, the enlargement of the liver and spleen, 
the mild anemia and the slight polynuclear leucocytosis are 
all so typical of the early stage of this disease that there can 
be no doubt that this is the true diagnosis. 

Prognosis. While some cases of this disease are said to 
have recovered, they are so few in number and the diagnosis 
in them is open to so much doubt that the prognosis is 
practically hopeless. He will, however, probably live for a 
number of years to die finally from cachexia or from the 
results of the pressure of the enlarged tracheo-bronchial and 
mediastinal glands on the adjacent organs. Remissions in 
the symptoms and temporary diminutions in the size of the 
glands may be expected. 

Treatment. Arsenic is the most useful drug in this disease. 
He should be given two drops of Fowler's Solution, well 
diluted with water, three times daily, after eating. The dose 
should be increased one drop daily until the limit of tolerance 
is reached. It should then be stopped for a few days, after 
which the dose should be two drops less than the one which 
caused the toxic symptoms. The drug should be given in 
this dose, with occasional intermissions, for many months. 
There is, of course, some danger of causing a peripheral 
neuritis. This happens comparatively seldom, however, and 
the good which the arsenic does justifies the risk. Treatment 
with the Roentgen ray has diminished the size of the glands 
in many instances and ought to be given a thorough trial. 
Local treatment is useless. The removal of the glands should 
not be undertaken unless they are causing serious symptoms 
from pressure on other organs. 



DISEASES OF THE BLOOD. 49I 

CASE 151. Charles C. was the first child of healthy 
parents. One younger child was well; there had been no 
deaths or miscarriages. He was born at full term, after a 
normal labor, was twenty-four inches long and weighed ten 
and one-half pounds. He was nursed entirely for five 
months, after which he was given diluted cows' milk in addi- 
tion. He cried almost constantly until he was fifteen months 
old, but did not vomit and had normal stools. He was 
always pale, however, and enlargement of the abdomen and 
spleen were noticed at that time. He had a very severe 
attack of whooping-cough when he was twenty months 
old, followed in a few months by chicken-pox and scarlet 
fever. 

Early in February, 1909, when nearly three years old, he 
vomited a large amount of blood and had a number of tarry 
stools. He was treated in the Children's Hospital for nine 
weeks. His blood at entrance showed 55% of hemoglobin, 
2,112,000 red corpuscles and 25,700 white corpuscles, of 
which 17% were lymphocytes and 83% polynuclear neutro- 
philes. There was no achromia and but little polychro- 
matophilia. The red corpuscles varied somewhat in size, 
but not in shape. The blood platelets were normal. Three 
days later the hemoglobin had dropped to 30% and the red 
corpuscles to 1,474,000, but the morphology of the red cells 
was unchanged. The blood, when he was discharged from 
the hospital two months later, showed 70% of hemoglobin, 
3,224,000 red corpuscles and 6900 white cells. The differen- 
tial count showed : 

Small mononuclears, 28.5% 

Large mononuclears, i-5% 

Polynuclear neutrophiles, 66.5% 

Eosinophils, 3-5% 

The red cells showed slight achromia and slight variation in 
size. There were no nucleated cells and the blood platelets 
were normal. 

The liver was palpable three cm. and the spleen four cm. 
below the costal border when he entered the hospital. When 
he was discharged the liver reached but one cm. below the 



492 CASE HISTORIES IN PEDIATRICS. 

costal border, while the size of the spleen was unchanged. 
The abdomen was rather large, but otherwise normal. The 
urine showed nothing abnormal and a skin tuberculin test 
was negative. 

He was perfectly well from that time on, except that he 
was pale and had a large abdomen. He ate everything and 
had no symptoms of indigestion. In February, 191 1, he had 
another attack, without known cause, in which he vomited 
a considerable amount of blood and had tarry stools. He 
was treated at that time in the Massachusetts General 
Hospital. His blood then showed 40% of hemoglobin and 
1,500,000 red corpuscles, but when he left the hospital 
it contained 65% of hemoglobin and 3,500,000 red cor- 
puscles. Nothing was found in the throat to account for 
the bleeding. 

He was seen March 11, 191 1, just after his discharge from 
the hospital. He was then five years old. He was very pale 
and weak. There was a venous hum in the neck and a 
systolic murmur over the whole precordia. The heart was 
otherwise normal. The lungs were normal. The liver was 
not palpable, but the spleen extended seven cm. below the 
costal border. He improved rapidly in every way after this 
and was well, except for an attack of diarrhea in July, 1911. 
He was admitted to the Children's Hospital for observation, 
August 3, 191 1, when five and one-half years old. 

Physical Examination. He was fairly developed and 
nourished and of fair color. His tongue was clean, his teeth 
in fair condition and his throat normal. There was a slight 
venous hum in the neck. The heart and lungs were normal. 
The upper border of the liver flatness was at the upper border 
of the sixth rib in the nipple line; the lower border was not 
palpable. The spleen was palpable eight cm. below the 
costal border. It was hard and smooth. The edge was 
rounded, but the notch was not felt. The abdomen was large 
and lax, but otherwise normal. The genitals were normal. 
There was no enlargement of the peripheral lymph nodes. 
The skin was normal and there were no scars of old eruptions, 
no mucous patches and no rhagades. The rectal tempera- 
ture was normal. 



DISEASES OF THE BLOOD. 493 

The urine was normal in color, acid in reaction, of a specific 
gravity of 1018 and contained neither albumin nor sugar. 



Hemoglobin, 


90% (Sahli) 


Red corpuscles, 


6,896,000 


White corpuscles. 


6,600 


Mononuclears, 


21% 


Polynuclear neutrophiles, 


79% 



The red corpuscles were normal in every way and there were 
no Plasmodia. 

A skin tuberculin test was negative. 

Diagnosis. The important points in this case are the 
recurrent hemorrhages, the temporary enlargement of the 
liver and the enlargement of the spleen. The blood has 
never shown anything more than the evidences of a second- 
ary anemia from hemorrhage and is now normal. Ulcer 
of the stomach can be ruled out on the rarity of this condition 
in early childhood, the absence of other symptoms of ulcer 
and the enlargement of the spleen. Hereditary syphilis, 
which is suggested by the enlargement of the spleen, can be 
excluded on the good family history, the absence of all other 
evidences of syphilis in the past or at present, the absence of 
enlargement of the liver and the fact that hemorrhages of 
this severity very seldom occur in syphilis except in the 
severest cases and in connection with other very marked 
symptoms of the disease. The enlargement of the spleen 
cannot be due to malaria, because there are no plasmodia in 
the blood and because hemorrhages do not occur in this 
disease. It is harder to exclude cirrhosis of the liver. The 
age at the onset of the symptoms, the absence of a cause, the 
normal size of the liver, which is almost invariably enlarged 
in cirrhosis in childhood, and the absence of ascites and 
jaundice seem sufficient, however, to rule it out. The 
hemorrhages show that the enlargement of the spleen is not 
merely the result of some disturbance of nutrition in the past. 
Pseudoleukemia can be excluded on the absence of enlarge- 
ment of either the superficial or deep lymph nodes after two 
and one-half years. The case undoubtedly belongs, there- 



494 CASE HISTORIES IN PEDIATRICS. 

fore, in the very indefinite class of diseases known as primitive 
splenomegaly, splenic anemia or Banti's disease. It does 
not correspond exactly, however, to any of the recognized 
types, simple splenomegaly, Banti's disease, the family or 
infantile form of Gilbert and Fournier or the chronic endo- 
thelioma of the spleen of Gaucher. The distinctions between 
these types are so indefinite clinically and there are so many 
cases that do not correspond to any of them that it hardly 
seems worth while to compare this case with each one of them 
in detail. The diminution in the size of the liver coincidently 
with an increase in the size of the spleen and the severe 
hemorrhages make it resemble, however, the picture of 
Banti's Disease more than that of the others. There is, 
however, no pigmentation of the skin and at present no 
anemia. 

Prognosis. If he does not die suddenly from hemorrhage, 
he will probably live for many years to eventually die with 
the symptoms of cirrhosis of the liver. There is, of course, 
no way to determine whether he will have more hemorrhages 
or not. The chances are, however, that he will. If he does, 
any one of them may prove fatal. 

Treatment. There is nothing to be hoped from medicinal 
treatment, as there is no drug that can affect in any way the 
size of the spleen or diminish the chances of hemorrhage. 
It is possible that treatment with the Roentgen ray may 
diminish the size of the spleen. This method should, there- 
fore, be tried. If it does not do so materially, the spleen 
should be removed, because if it is not removed he is liable 
to a hemorrhage, which may prove fatal, at any time. The 
spleen is not adherent, the boy is in good condition and 
should, therefore, stand the operation well. The chances of 
death from the operation are, therefore, less than the chances 
of death from hemorrhage if the spleen is »ot removed. 



SECTION XII. 
DISEASES OF THE NERVOUS SYSTEM. 

CASE 152. Ronald P., six years old, was the only child of 
very nervous parents. His father was alcoholic, but there was 
no history of syphilis. His home surroundings were very 
exciting and he was under little control. He had an ungov- 
ernable temper and was in the habit of biting, fighting and 
swearing when opposed. He had had the croup every winter, 
but no other affections of the respiratory tract. His diet 
was a fair one for the country, and his appetite and digestion 
were good. He had had no other illnesses. 

Three months before he was seen in consultation he began 
to throw his arms up over his head in a peculiar manner, the 
motions always being the same. A diagnosis of chorea was 
made by his physician and he was given Fowler* s solution. 
Soon after taking this he began to clear his throat constantly, 
while there was no diminution in the movements of his arms. 
More than nine drops of Fowler's solution a day caused 
edema of the eyelids, congestion of the conjunctivae and a 
nasal discharge. He had taken it fairly regularly in small 
doses, however, up to the time he was seen. He had begun 
to shrug his shoulders about six weeks before. The peculiar 
motions of the arms, the clearing of the throat and the 
shrugging of the shoulders all persisted. The movements 
and the clearing of the throat ceased during sleep. He did 
not seem sick in other ways. 

Physical Examination. He was fairly developed and 
nourished and of good color. He was very excitable and was 
constantly clearing his throat and shrugging his shoulders 
during the examination. He could keep still when he tried. 
The pupils were equal and reacted to light and accommoda- 
tion. There was no coryza and he kept his mouth shut. 
Examination with the finger showed no adenoids. The throat 
was normal. The tongue was clean and was protruded 

495 



496 CASE HISTORIES IN PEDIATRICS. 

without tremor. The heart, lungs and abdomen were normal. 
The liver and spleen were not palpable. The extremities 
were normal. There was no spasm or paralysis. The knee- 
jerks w^ere equal and slightly diminished. Kernig's and 
Babinski's signs were absent. There was no ankle clonus. 
The cremasteric reflexes were normal, the abdominal lively. 
The genitals were normal. There was no enlargement of 
the peripheral lymph nodes. There was no eruption and no 
irritation of the skin. 

Diagnosis. The diagnosis lies betweeen chorea and habit 
spasms. The clearing of the throat is not at all like chorea, 
the motions are limited in number and always the same, he 
can control them to a considerable extent, and there is no 
tremor of the tongue. Chorea can, therefore, be excluded 
and a positive diagnosis of Habit Spasms made. These are 
especially likely to develop in children of neurotic parentage 
and living in exciting surroundings, as in this instance. 
There is usually some local cause for the development of 
the individual spasms, such as an uncomfortable hat, a 
badly fitting collar or a poorly adjusted suspender. No 
definite cause for the motions of the arms and the shrugging 
of the shoulders was made out in this boy. The irritation 
of the nose and throat caused by the arsenic was presumably 
the primary cause of the clearing of the throat; its continu- 
ance is due to the underlying neurotic condition. 

Prognosis. These habit spasms never lead to chorea. 
They are likely to persist for long periods, however, or to 
be replaced by others, because, even if the local cause can 
be found and removed and the individual spasm relieved, it 
is very difficult to get at the underlying trouble, that is, the 
inherited neurotic temperament. The prognosis is worse 
than usual in this instance, because the home surroundings 
are so bad and because he has not been controlled in the past. 

Treatment. The treatment of habit spasms can be divided 
into three parts: that directed to the removal of the local 
cause of the individual spasm, if it is still present; that of 
the individual spasm ; and that directed to the improvement 
of the underlying neurotic condition. Nothing was found 
in this instance to account for the peculiar motions of the 



DISEASES OF THE NERVOUS SYSTEM. 497 

arms or the shrugging of the shoulders. The local cause, 
whatever it was, must, therefore, have been accidentally 
remedied. The best treatment for the shrugging of the 
shoulders and the motions of the arms is to have him make 
these motions before a mirror for several minutes, several 
times daily. What is at present an involuntary act will 
come by practice under the control of the will again and hence 
be performed only voluntarily. The arsenic, which was, by 
the irritation which it caused, presumably the original cause 
of the clearing of the throat, has already been stopped. It 
is possible, however, that some local irritation still persists. 
This can be treated by some mild alkaline or oily spray like 
the liquor antisepticus alkalinus of the Pharmacopeia, or 
the following mixture: 

Menthol, i gr. 

Camphor, i gr. 

Liquid albolene, i oz. 

The treatment of the underlying neurotic condition is a 
very difficult matter. It includes, in the first place, regula- 
tion of his home surroundings in general. It is probable that 
little can be done in this direction. His diet, exercise, amuse- 
ments and rest must all be carefully laid out. He must have 
much fresh air and ought not to go to school at present. 
Drugs will probably not be of much assistance, although 
the tincture of nux vomica in five-drop doses, three times 
daily, before meals, and eisenzucker or ferratin in five- 
grain doses, three times daily, after meals, may be of some 
assistance. 



498 CASE HISTORIES IN PEDIATRICS. 

CASE 153. Miriam T., three years old, was the first child 
of nervous and not very vigorous parents. She had always 
been somewhat delicate and very excitable. She had for 
some weeks been having one or more attacks, almost every 
evening, in which she cried out as if in terror. She was 
usually awake by the time her mother or her nurse reached 
her and was almost always able to tell what it was that she 
feared. These were usually things which she had seen or 
heard about during the day. It was learned, on questioning, 
that both her mother and her nurse had been in the habit of 
reading and telling stories to her, which were much too old 
for her. She had recently been unwilling to go to sleep in 
her room alone. Her diet was a good one and she had only 
cereal and bread with milk for supper. She had no symptoms 
of indigestion. She was a very active child and wanted to 
be on her feet all the time. She had a rest of an hour at noon, 
but did not go to sleep. She was, therefore, as a rule, very 
tired and irritable by night. 

Physical Examination. She was fairly developed and 
nourished and of good color. She was mentally precocious 
and highly excitable, but docile and easy to examine. There 
was no nasal discharge or obstruction. Her tongue was clean. 
There was no enlargement of the tonsils and no adenoids 
could be felt with the finger. The heart, lungs and abdomen 
were normal. The liver and spleen were not palpable. The 
extremities were normal. There was no spasm or paralysis. 
The knee-jerks were equal and unusually lively. There was 
no enlargement of the peripheral lymph nodes. 

Diagnosis. There can be no doubt, of course, as to the 
diagnosis of Pavor Nocturnus. The normal condition of 
the nose and throat shows that the attacks cannot be due to 
imperfect oxygenation as the result of obstruction to the 
respiration. The absence of all symptoms and signs of 
indigestion, together with the fact that she has a light supper, 
rule out indigestion as the cause. Moreover, when night 
terrors are due to disturbances of the digestion, the children 
are very seldom able to tell of what they are afraid ; in fact, 
they often do not know, when awakened, that they have cried 
out or been afraid. When night terrors are due to an un- 



DISEASES OF THE NERVOUS SYSTEM. 499 

Stable and overstimulated nervous system, however, the 
children almost always know of what they are afraid, not 
only during the attack, but also after they are awake. The 
attacks in this instance are of this type. It is easy to see why 
her nerv^ous system is unstable and overstimulated. She is 
the neurotic child of neurotic parents, plays too hard and has 
too little rest, and is excited and worried by stories which 
require an excessive amount of mental effort on her part or 
which she can only partly understand. 

Prognosis. The attacks will gradually diminish in fre- 
quency and finally cease, if her life is so regulated that she 
does not get overtired, either physically or nervously, and 
hears only such stories as are suitable for her age. 

Treatment. The treatment consists in regulating her life 
so that she does not get overtired, in guarding her from 
excitement and in stopping all stories which are liable to 
disturb or frighten her. She must not be allowed to run 
about as much as she pleases, but must be wheeled in her 
carriage or taken out to drive a part of the time. She must 
have a long rest at noon and get to bed by half-past five in 
the afternoon. She must be left to amuse herself as much as 
possible and must not be played with any more than is 
absolutely necessary. She ought not to see anyone outside 
of her immediate family. If any stories are told to her, they 
must be simple and have nothing in them v/hich is unpleasant 
or exciting. It will be well to give her ten grains of the 
bromide of soda at bedtime for a few nights in order to break 
the habit of waking up in the early evening, into which she 
has fallen. 



500 CASE HISTORIES IN PEDIATRICS. 

CASE 154. Porter M., four years old, was the fourth child 
of healthy parents. He was born at full term after a normal 
delivery and was normal at birth. His father had had several 
convulsions when a child. One of his brothers, ten years old, 
was in an asylum for epileptics for convulsions which began 
after a fall out of bed at two years. 

He had always been perfectly well up to six months before, 
when, in common with his sister, he had an acute attack of 
fever and vomiting, apparently due to drinking milk from a 
sick cow. Both had convulsions at the onset of the illness. 
His sister had no more. He was in bed four days and had 
several convulsions during that time. His next convulsion 
was two weeks after he was up and about. Since then he 
had had a great many convulsions, lasting from one to five 
minutes. His mother thought that he did not lose con- 
sciousness in them. He never frothed at the mouth, bit 
his tongue or passed urine or feces. He also had many very 
short attacks in which he apparently lost consciousness 
momentarily, dropped things, stared for an instant and so 
on, but never fell down. Various diets had been tried with- 
out effect. He was for some time on a strictly vegetable 
diet, at another had nothing but malted milk for a month, 
and at another only milk, bread and cookies. His appetite 
was good and he had no signs of indigestion except that 
he was ver> constipated. The movements at times con- 
tained mucus, but were otherwise normal. He had been 
circumcised and had adenoids removed without any effect 
on the convulsions. His mental condition was perfectly 
normal. 

About six weeks before he was seen in consultation the 
convulsions became much more frequent and severe and 
bromide was begun. Since small doses had no effect on the 
convulsions, the dosage was increased until he was taking 
enormous amounts with the addition of chloral. Since 
taking the bromide he had become so stupid that he could 
not hold up his head or hold things in his hands, kept his 
mouth open and drooled constantly. His appetite had 
fallen off and he had lost considerable weight. The severe 
attacks were relieved by the bromide, but he continued to 



DISEASES OF THE NERVOUS SYSTEM. 501 

have the mild ones. The bromide had been diminished during 
the last week and he had begun to be more like himself. 

Physical Examination. He was fairly developed and 
nourished and moderately pale. He took very little notice 
of his surroundings, although at times he brightened up 
momentarily and appeared perfectly normal mentally. He 
held up his head with some difficulty and could hardly sit 
alone. He could walk w^ith help, but very feebly and un- 
steadily. He kept his mouth open and drooled constantly. 
There was no spasm or paralysis of any of the muscles con- 
trolled by the cranial nerves. The fundi of the eyes showed 
nothing abnormal. The ear-drums were normal. The tonsils 
were large, but not inflamed. The tongue was considerably 
coated. The heart, lungs and abdomen were normal. The 
lower border of the liver was just palpable in the nipple 
line. The spleen was not palpable. The extremities were 
normal. There was no spasm or paralysis. All his motions 
were, however, unsteady and feeble. The knee-jerks were 
equal and normal, as were the abdominal and cremasteric 
reflexes. Kernig's and Babinski^s signs were absent. The 
sensation to touch and pain was slightly dulled. He was 
circumcised. There was no enlargement of the peripheral 
lymph nodes. 

The urine showed nothing abnormal. 

Diagnosis. The bromide intoxication obscures the diag- 
nosis to a certain extent. There is but little doubt, however, 
that the stupidity and muscular weakness are due to the bro- 
mide and not symptoms of any cerebral disease. The omis- 
sion of the bromide will quickly settle this point. The absence 
of spasm, paralysis, changes in the reflexes and of Kernig's 
and Babinski's signs, and the normal condition of the 
fundi, prove that there is no gross cerebral lesion. The 
diagnosis lies, therefore, between ''idiopathic" epilepsy and 
reflex convulsions, presumably from disturbance in the 
digestive tract, since all other causes of reflex convulsions 
are excluded by the physical examination. The family 
history is of but little aid, as the tendency to convulsions 
from slight causes, shown in the father and sister, balances 
the epilepsy in the brother. The onset of the convulsions 



502 CASE HISTORIES IN PEDIATRICS. 

with the onset of an acute disease is somewhat against 
epilepsy, but does not by any means exclude it, because the 
first convulsions may have caused some cerebral lesion which 
resulted in epilepsy, or the acute disease may have lighted 
up a latent epilepsy. The nature of the attacks, which, 
according to the parents, are not accompanied by an initial 
cry or loss of consciousness, is somewhat against epilepsy, 
but does not exclude it, because a cry is often lacking in 
epilepsy and because the parents may be wrong as to the 
retention of consciousness. In fact, they probably are, be- 
cause if he loses consciousness in the slight attacks he almost 
certainly does in the more severe ones. On the other hand, 
the symptoms of disturbance in the digestive tract are hardly 
severe enough to make it probable that there is sufficient 
intestinal irritation or toxic absorption from the intestines 
to cause so many and so severe convulsions. Regulation of 
the diet and of the bowels has had, moreover, no effect on 
the number or severity of the convulsions. The chances 
are, therefore, that the condition really is Epilepsy. The 
only way to settle the diagnosis positively, however, is by 
careful regulation of the diet, bowels and general routine 
for a considerable time. If the convulsions persist, the 
diagnosis of epilepsy will be confirmed; if they cease, it will 
have to be changed to reflex convulsions. 

Prognosis. The prognosis depends on the final diagnosis. 
If this is epilepsy, there is a possibility of recovery, but the 
chances are very much against it. The convulsions will, 
however, probably become much less frequent but more 
severe. 

Treatment. The bromide should be stopped for the 
present in order to determine positively as to his mental and 
physical condition. He should be put on a diet of milk and 
starches to diminish intestinal putrefaction and his bowels 
kept freely open, preferably with some mild saline, like 
phosphate of soda. There is no objection to adding fruit 
and green vegetables to the diet for their laxative action. 
He must, of course, be carefully watched to prevent him from 
injuring himself during the attacks. 



DISEASES OF THE NERVOUS SYSTEM. 503 

CASE 155. Francis M., eight years old, was the second 
child of healthy parents. The other child died of diarrhea 
in infancy. There had been no miscarriages. There was 
no history of epilepsy in either family. He was born, at full 
term, after a normal labor, and was normal at birth. He 
was breast-fed for eighteen months and was well, except for 
mumps at three and one-half years, until he was four years 
old. At this time he had a series of convulsions lasting twelve 
hours, followed by a period of unconsciousness lasting thirty- 
six hours, as the result of an indiscretion in diet following a 
long walk and playing in the sun all day in August. He was 
treated in the Children's Hospital at that time and no cause 
for the convulsions and unconsciousness was found outside of 
the indiscretion in diet and exposure to heat. He was dis- 
charged well at the end of a week. 

He began to have convulsions soon after this and had 
continued to have them. He usually had one or two con- 
vulsions a week, but sometimes went two or three weeks 
without any. They ordinarily came in the early morning, 
during sleep, and lasted four or five minutes, after which he 
slept until it was time to get up. He was backward at school, 
probably because he did not go to school until he was seven 
years old. His teacher said that he learned fairly easily, but 
that at times he seemed uninterested. At home he was mis- 
chievous and hard to manage. 

Four weeks before he was seen, twitching of the right arm 
and leg, with some weakness and awkwardness of that side, 
developed and he began to drag his right foot a little when he 
walked. His speech became a little indistinct. He was 
restless at night and tossed about the bed, but did not twitch 
when he was asleep. His appetite continued good and his 
bowels regular. 

Physical Examination. He was well developed and nour- 
ished and of good color. He seemed perfectly normal 
mentally, but his speech was a little indistinct. The pupils 
were equal and reacted to light and accommodation. The 
fundi were normal. His tongue was protruded in the median 
line and was decidedly tremulous. The throat was normal. 
There were frequent, involuntary twitching movements of 



504 CASE HISTORIES IN PEDIATRICS. 

both sides of the face. There was no rigidity of the neck or 
neck sign. The heart, lungs, abdomen and genitals were 
normal. The liver and spleen were not palpable. The 
extremities were normal. There were frequent involuntary 
movements of the right arm and leg, and occasionally of the 
left arm and leg. The involuntary movements all ceased 
when he was asleep. He walked somewhat awkwardly and 
had rather poor control of his right leg. He was unable to 
make fine movements with his right arm. There was no 
spasm or paralysis. The knee-jerks were equal and normal. 
Kernig^s and Babinski's signs were absent. There was no 
wasting of the muscles and no disturbance of sensation to 
touch or pain. There was no enlargement of the peripheral 
lymph nodes. The mouth temperature was 98.6° F. ; the 
pulse, 90; the respiration, 16. 

He was seen in a convulsion. The convulsion was general 
and clonic and was not preceded by a cry. It lasted about a 
minute, after which he slept for an hour. The face was 
cyanotic. There was no frothing at the mouth, but he would 
have bitten his tongue if the jaw had not been held. 

Diagnosis. The character of the convulsions, their fre- 
quent repetition without obvious cause, the fact that they 
occur more often at night than during the day, together with 
the fact that up to the last month there have been no other 
symptoms of disturbance of the nervous system, justify a 
positive diagnosis of Idiopathic Epilepsy. The next point 
to be decided is whether the new symptoms which have 
appeared within the last month are manifestations of the 
same cerebral lesion which causes the epilepsy or of some 
entirely distinct condition. The facts that the involuntary 
motions are more marked on the right side than on the left, 
that the right arm and leg are not used as well as the left and 
that there is a disturbance of the speech, suggest that there 
is a lesion of the cortex in the left motor area. The involun- 
tary motions are, however, not limited to the right side, they 
are equally active on both sides of the face, the tongue is 
protruded in the median line, the disturbance in speech is not 
aphasic in character but merely a manifestation of awkward- 
ness in the use of the tongue, the fundi are normal, there is 



DISEASES OF THE NERVOUS SYSTEM. 505 

no Spasm of the extremities and the deep reflexes are normal. 
These points are sufficient to rule out a localized cortical 
lesion and point very strongly to chorea. The tremulousness 
of the tongue is very strong evidence in favor of this diag- 
nosis, while the fact that the motions stop during sleep justi- 
fies, in connection with other evidence, a positive diagnosis 
of Chorea. 

Prognosis. The chorea is of a relatively mild type and 
recovery may be expected in a few weeks. The only danger 
from the chorea is of a complicating cardiac lesion. The 
chances of recovery from the epilepsy are very small, although 
better than they would be if he was an adult. The con- 
vulsions will, however, probably become less frequent but 
more severe. 

Treatment. The most valuable thing in the treatment of 
chorea is quiet, both physical and mental. He should be 
put to bed and kept there until the symptoms are much 
improved, and then allowed to get up gradually. He ought 
to be left by himself as much as possible. Whoever is with 
him must be quiet and he must be amused in quiet ways. 
Visitors should not be allowed. He should, of course, be 
given all the fresh air and sunlight possible. The next most 
important point in the treatment is the regulation of the 
diet. He must be fed liberally with food suitable for his age, 
due consideration being paid to the fact that he is in bed. 
There are no special indications as to the kind of diet in 
chorea. It will be well, however, to keep the meat and eggs 
low in this instance, because of the epilepsy. It will be wise, 
on account of the undoubted relationship between chorea and 
rheumatism, to give him five grains of aspirin, three times 
daily, after meals, for a time, in order to diminish the chances 
of the development of endocarditis. His appetite, digestion 
and color are good and there is, therefore, no indication for 
the administration of a tonic. Arsenic, in the writer's 
opinion, has no specific action in chorea, whatever good it 
may do being due to its action as a tonic. It is not indicated, 
therefore, in this instance. A warm bath at bedtime will un- 
doubtedly quiet him and may be given oftener, if necessary. 
If he becomes more restless, he may be wrapped in a cold, 



5o6 CASE HISTORIES IN PEDIATRICS. 

wet sheet, with a blanket outside, and left in it for an hour 
daily. 

The autoserum treatment of chorea is often accompanied 
by severe and sometimes by alarming reactions and is seldom 
of benefit. The vaccine and serum treatments are useless. 
It will not be justifiable, therefore, to use any of them in this 
instance. 

It will be well to give him twenty grains of bromide of soda 
at bedtime for the epileptic convulsions. It is not necessary 
to give it during the day, because his convulsions are almost 
entirely nocturnal. The bromide will have more effect if 
salt is largely ehminated from his diet. It will probably be 
necessary for him to take bromide for a long time, perhaps 
in considerably larger doses. In giving it, it must not be 
forgotten, however, that in childhood, bromide has a very 
depressing action both on the mind and body and that, unless 
used with discretion, it may do far more harm than good. 



DISEASES OF THE NERVOUS SYSTEM. 5^7 

CASE 156. Mary B., two years old, was the second child 
of extremely neurotic parents. She had always been far 
ahead of her age in her mental development. She was not 
nursed but was fed during the first year on modified milk, 
prepared at home, and then on a very careful diet. She had 
always been very constipated and had had various laxatives, 
enemata and suppositories almost constantly since birth. 
Her digestion, except for occasional acute upsets, had been 
otherwise fairly good. She had had no other illnesses except 
two attacks of bronchitis and a mild attack of pyelitis. She 
sat up alone at eleven months and walked at twenty months. 
She cut her first tooth at ten months, but had eight when a 
year old. 

She began to have convulsions when a year old. She 
almost always had one or two, and often as many as half a 
dozen, daily. The longest interval between convulsions 
during the year had been ten days. They almost always 
came on when she was angry, frightened or in pain. A fit 
of crying almost always ended in a convulsion. She would 
often have one if she was refused anything which she wanted. 
A fall or a bump was usually followed by one. She often had 
one during defecation, if the movement was hard. She was 
seen in one, which came on as the result of a rectal examina- 
tion. She cried, held her breath and became a little blue. 
She then gave a short cry, stiffened out, raised her clenched 
hands before her face and then slowly dropped them. She 
was not cyanotic, breathed regularly during the attack, 
made no other movements, lost consciousness and passed 
both urine and feces. The attack did not last more than half 
a minute. She was dull and pale for several minutes after 
it. Her mother said that this was an unusually severe one 
and that many of them were merely slight *' fainting spells." 
The attacks occurred more frequently when the bowels were 
not moving freely, when she was cutting teeth, when she 
was not kept free from excitement, and when she was below 
par physically. She had never had any definite attacks of 
laryngismus stridulus, and Trousseau's symptom and the 
facial phenomenon had been absent at repeated examinations. 

Physical Examination. She was small but fairly nourished. 



50S CASE HISTORIES IN PEDIATRICS. 

Her flesh was firm and her color good. Her mental develop- 
ment was nearer that of a child of three than of two years. 
The anterior fontanelle was not quite closed. There was no 
craniotabes. She had sixteen teeth. Her mouth and throat 
were normal and her tongue clean. There was no spasm or 
paralysis of any of the muscles controlled by the cranial 
nerves. There was a slight rosary. The heart, lungs and 
abdomen were normal. The liver was just palpable in the 
nipple line. The spleen was not palpable. The extremities 
were normal. There was no spasm or paralysis. The knee- 
jerks were equal and normal. Kernig's and Babinski*s signs 
were absent, as were Trousseau's sign and the facial phe- 
nomenon. There was no enlargement of the peripheral 
lymph nodes. 

The urine was pale in color, acid in reaction and of a specific 
gravity of 1,015. It containd neither albumin nor sugar. 
The sediment showed nothing abnormal. 

Diagnosis. The absence of Trousseau's symptom, the 
facial phenomenon and attacks of laryngismus stridulus 
shows that the convulsions are not manifestations of the 
spasmophilic diathesis (see Cases 100 and 164). The absence 
of spasm and paralysis, the normal condition of the reflexes, 
the absence of Kernig's and Babinski's signs and the normal 
mental development rule out any gross cerebral lesion. The 
diagnosis lies, therefore, between " idiopathic epilepsy " and 
reflex convulsions from slight causes in a child with an unu- 
sually irritable nervous organization. The character of the 
convulsions and their long continuance are in favor of epilepsy. 
The strongest point against it is the fact that the convulsions 
never occur without some definite cause. This fact, while 
it does not rule out epilepsy, is important enough to more 
than counterbalance the character and continuance of the 
convulsions and to make epilepsy very improbable. The 
chances are, therefore, against epilepsy and in favor of 
Reflex Convulsions. Time alone, however, can settle the 
diagnosis positively. If they persist after she grows older and 
can be better controlled, the diagnosis will have to be changed 
to epilepsy. 

Prognosis. The convulsions will probably gradually 



DISEASES OF THE NERVOUS SYSTEM. 5^9 

diminish in frequency and finally cease as she grows older 
and can be reasoned with and taught self-control. 

Treatment. The treatment consists in regulation of her 
diet and bowels, and in training her in self-control. This 
will, however, be very difficult because crossing her is very 
likely to bring on a convulsion. She must be made to obey 
and to lead a normal life even if the number of convulsions is 
temporarily increased, as in this way only can she be con- 
trolled. Quiet surroundings and freedom from excitement are 
especially important in this connection. There is no direct 
indication for medicinal treatment. Everything which will 
tend to improve her physical condition is, of counse, of im- 
portance. The most minute details of her life must be looked 
into and regulated. 



5IO CASE HISTORIES IN PEDIATRICS. 

CASE 157. Frances B., five years old, was the only child 
of neurotic parents, belonging to neurotic families. There 
had been no other pregnancies. She had always been per- 
fectly well except for occasional ''colds" and an attack of 
pneumonia a few months before. She had, however, always 
been very excitable and unusually bright for her age. It was 
noticed when she was only a few months old that she often 
rubbed her legs together and appeared to enjoy it. A little 
later it was noticed that she would stop after a short time and 
perspire freely. The real significance of this was not appre- 
ciated, however, until she was about three years old. She 
had done it only when undressed and in bed up to a 
year before, since when she had also done it when up and 
dressed. She rubbed her legs together without any very 
wide motions and had perfectly definite orgasms with re- 
laxation and perspiration. She had been reasoned with 
and mildly punished, but was apparently unable to con- 
trol herself when left alone. There had been no increased 
frequency of micturition and no pain on micturition. No 
pin-worms had been seen on repeated examinations. Her 
hygienic surroundings, diet and care were ideal. She had 
been especially protected against overexcitement and over- 
fatigue. 

Physical Examination. She was well developed and nour- 
ished and of good color. In fact, she was the picture of 
health. She was very forward mentally, but did not appear 
unduly nervous or excitable. No adenoids were felt with the 
finger. Her tongue was clean, her teeth good and her throat 
normal. The heart, lungs and abdomen were normal. The 
liver and spleen were not palpable. The extremities were 
normal. There was no spasm, paralysis or disturbance of 
sensation. The knee-jerks were equal and normal and there 
was no Kernig's sign. There was no enlargement of the 
peripheral lymph nodes. The internal surfaces of the labiss 
were slightly reddened. The prepuce was adherent to the 
clitoris, but there was no evidence of local irritation. There 
was no vaginal discharge. 

The urine was pale, slightly acid in reaction, of a specific 
gravity of 10 15 and contained no albumin or sugar. 



DISEASES OF THE NERVOUS SYSTEM. 5II 

Diagnosis. This habit, which is usually spoken of as 
masturbation, is better described by the term. Pseudo- 
masturbation, because, although it is sometimes associated, 
as in this instance, with a definite orgasm, it does not and 
cannot have at this age the same significance as in later 
childhood and adult life. At this time it is simply a habit, 
like picking the nose, indulged in because it is pleasant and 
without any definite purpose or sexual idea. Further evi- 
dence that this habit is not true masturbation is her good 
general condition and her normal intelligence, which show 
that neither her mental nor her physical development have 
been in any way affected by it. It is a habit that must be 
stopped, however, because, if it is not, it will, as she grows 
older, lead to true masturbation. 

Prognosis. It will be unusually difificult to break up the 
habit in this instance, because it has persisted since early 
infancy and is increasing. She is, moreover, old enough to 
have a strong will of her own, but not old enough to have 
much moral sense or to be very successfully reasoned with. 
Her neurotic tendencies will make her harder to control, but, 
on the other hand, her mental forwardness will make it easier 
to reason with her. 

Treatment. In the first place all sources of local irritation 
must be removed. The urine is normal and there are no pin- 
worms in this instance. The slight irritation of the inner 
surfaces of the labiae is probably an effect rather than a cause. 
It should, however, be treated with some simple salve, like 
boracic acid ointment. It will be wise to strip back the 
foreskin, under ether if necessary, and remove any smegma 
that may be present. Amputation of the clitoris, as is some- 
times recommended, is absolutely unjustifiable. Her drawers 
and night clothes should be lined with linen, wherever they 
come in contact with the inner surface of the thighs and 
genitals. Nothing will be gained by punishment. It will be 
much more likely to make her tricky and deceitful than to 
stop the habit. She must be told not to do it, but told in 
the same way that she would be told to stop picking her nose 
or biting her nails. If it is spoken of as if it were some 
terrible thing or too much made of it, the result will be to 



512 CASE HISTORIES IN PEDIATRICS. 

attract her attention to it and make her-^do it more. Great 
tact must be used in talking with her not to suggest the habit 
to her. 

She must be watched constantly during the day, but in 
such a way that she does not realize that she is under sur- 
veillance. Someone must stay in the room with her, if she 
has a rest at noon. She must not be left alone at night until 
after she has gone to sleep. Someone must sleep in the room 
with her to prevent her from doing it when she wakes in the 
morning. If this plan is not feasible or sufficient, an appara- 
tus consisting of an iron bar firmly attached to a band about 
each thigh, which will prevent her from rubbing her thighs 
together, may be applied. 



DISEASES OF THE NERVOUS SYSTEM. 513 

CASE 158. Eva C. was the second child of healthy parents. 
Two other children were well. There had been no deaths 
or miscarriages. She was born at full term and was thought 
to have been normal at birth. A physician who saw her when 
she was eleven weeks old, because of a convulsion, told her 
parents, however, that her head was small. She had had 
repeated slight convulsions since that time, except when she 
was taking bromide. She was nursed for a year. Since then 
she had had only liquids, because she refused to chew or 
swallow anything solid. She had never had any disturbance 
of the digestion. She was very backward in every way. She 
sat up first at one year and cut her first tooth at the same time. 
She had never held things in her hands. Her parents thought 
that she noticed light, but nothing else. They were sure that 
she did not hear. She rolled her head from side to side con- 
stantly, except when she was asleep. She seldom cried. 
She was seen when seventeen months old. 

Physical Examination. She was well developed and 
nourished, and of good color. The shape of her head was 
very peculiar, in that there was almost no occiput. The face 
and forehead were normal. The anterior fontanelle was 
closed. The occipi to-frontal circumference of the head was 
37.5 cm. ; that of the chest at the level of the nipples, 46 cm. 
The average circumference of both at this age is about 46 cm. ; 
that of the head being slightly the larger. The antero- 
posterior diameter of the head was 12 cm. ; the lateral, 10 cm. 
The pupils were equal and reacted to light. She did not, 
however, notice anything, even light. The fundi showed 
nothing abnormal. She did not pay any attention to sounds. 
The mouth, throat and tongue were normal. She had three 
teeth. The thyroid was indistinctly palpable. She held her 
head up well, but sat up very unsteadily. There was no 
rosary. The heart, lungs and abdomen were normal. The 
lower border of the liver was palpable three cm. below the 
costal border in the nipple line. The spleen was not palpable. 
The extremities showed nothing abnormal. There was no 
spasm or paralysis. The knee-jerks were equal and normal. 
Kernig's sign was absent. She would not hold anything in 
her hands, even when it was placed in them. Sensation to 



514 CASE HISTORIES IN PEDIATRICS. 

touch and pain was normal. The skin was soft and there was 
no eruption or scars of old eruptions. Her hair was fine and 
thick. There was no enlargement of the peripheral lymph 
nodes. 

Diagnosis. She is unquestionably a low-grade idiot. 
There are no signs of cretinism. The history is not that of 
amaurotic idiocy and the fundi are normal. The face is 
not of the Mongolian type. The head is not hydrocephalic, 
but is much smaller than normal. The diagnosis of Micro- 
cephalic Idiocy is, therefore, without doubt, the correct one. 

Prognosis. Very little improvement can be expected. 
She will always be a very low-grade idiot. The chances are, 
however, that she will not live to grow up, but will die of some 
intercurrent disease within the next one or two years. 

Treatment. There is nothing to do for her except to feed 
her and keep her warm and clean. Craniectomy is a useless 
procedure, because the small size of the head is not due to a 
premature closing of the fontanelles and sutures, but to the 
small size of the brain. The mental defect is not caused by 
pressure of the bones on the brain, but is due to a congenital 
cerebral malformation. The fontanelles and sutures close 
early and the head is small because, on account of the small 
size of the brain, the intracranial pressure is not sufficient to 
keep the bones apart. She may be given five grains of the 
bromide of sodium from three to six times daily, if the con- 
vulsions persist and are severe. 



DISEASES OF THE NERVOUS SYSTEM. 515 

CxASE 159. Joseph C. was the first child of healthy Jewish 
parents. There had been no miscarriages. He was born at 
full term after a normal labor and was normal at birth, 
although very small. He was breast-fed entirely until he 
was eight and one-half months old, after which he was ration- 
ally fed. His digestion had always been good. He " acted 
just like any other baby " until he was three or four months 
old, smiled, took things in his hands, was interested in his 
surroundings and kicked out with his legs. He had not 
learned to hold up his head, however. He then ceased to 
develop mentally and soon began to deteriorate, so that 
when he was eight months old his parents were sure that he 
was '* not bright." He became dull and stupid, did not notice, 
would not hold things in his hands and seldom moved. 
Rigidity of the extremities developed when he was fourteen 
months old, and twitching of the face when he was seventeen 
months old. He began to have convulsions a few days before 
he was seen, when eighteen months old. He had taken his 
food well up to a few days before, when he began to have 
difficulty in swallowing. 

Physical Examination. He was fairly developed and nour- 
ished, but markedly pale. His head was of good shape and of 
normal size. The anterior fontanelle was 3 cm. in diameter 
and slightly depressed. There was no craniotabes. He was 
unable to hold up his head, which rolled limply from side to 
side. He heard but could not see. The pupils were equal 
and reacted to light. His expression was vacant. He kept 
his mouth open and drooled constantly. He had six teeth. 
The throat was normal and there were no adenoids. He could 
not sit up. The back showed a marked curve of weakness. 
There was a moderate rosary. The heart, lungs and abdomen 
were normal. The liver was palpable i cm. below the costal 
border in the nipple line. The spleen was not palpable. He 
lay on his back and seldom moved, except to turn his head. 
He held his hands flexed at the wrists, with the fingers 
partially flexed. There was, however, very little resistance 
to passive extension of the fingers and hands. The arms 
dropped flaccidly when lifted up. He usually held his legs 
and feet extended. There was at times marked opposition to 



51 6 CASE HISTORIES IN PEDIATRICS. 

passive motions; at others, the legs were perfectly flaccid. 
The knee-jerks were usually absent; when present, they 
were very feeble. The cremasteric and abdominal reflexes 
were present. There was no ankle clonus. Kernig's and 
Babinski's signs were absent. Sensation to both touch and 
pain was present. There was a slight general enlargement 
of the peripheral lymph nodes. There was no eruption and 
there were no scars of old eruptions. There were no mucous 
patches about the mouth or anus and no rhagades about the 
mouth. The rectal temperature was 99° F. ; the pulse, no; the 
respiration, 30. He weighed seventeen and one-half pounds. 

The urine was high in color, acid in reaction and of a specific 
gravity of 1,024. It contained neither albumin nor sugar. 
The sediment showed an excess of urates, but no cells or casts. 

Diagnosis. This boy is undoubtedly an idiot. His race, 
the normal condition at birth, the normal development for 
some months followed by progressive physical and mental 
deterioration, taken together with the general flaccidity and 
the blindness, form a combination so characteristic of Amau- 
rotic Idiocy that a positive diagnosis of this condition is 
justified without further examination. There is no other 
condition which shows just this combination of history and 
physical signs. The diagnosis should, however, be verified 
by an examination of the fundi which in this disease present 
a picture which is absolutely pathognomonic. This is a dark, 
reddish-brown, circular spot occupying the site of th^ macula 
lutea and surrounded by a whitish zone about twice the 
diameter of the optic disk. The eyes of this boy were exam- 
ined and the characteristic picture found, thus verifying the 
diagnosis. 

Prognosis. The prognosis is absolutely hopeless. If he is 
not fed with a tube, he will quickly starve to death. If he is 
fed with a tube, he may live for many months. Sooner or 
later, however, he will die of bronchopneumonia or some other 
intercurrent disease. 

This disease is preeminently a familial one. The chances 
are, therefore, that if his parents have more children, some 
or all of them will be afilicted with the disease. They may, 
however, all escape. 



DISEASES OF THE NERVOUS SYSTEM. 517 

Treatment. There is no treatment for this disease. Nothing 
can be done to relieve it or to shorten its course. It is not 
justifiable to let him die of starvation. He must be fed 
with a stomach tube, therefore, and taken care of until he 
dies. 



51 8 CASE HISTORIES IN PEDIATRICS. 

CASE 1 60. Helen T.'s parents were feeble but not alco- 
holic or especially nervous. One other child was well. There 
had been no deaths or miscarriages. 

She was born at full term after a normal labor, and seemed 
normal at birth. She had always been fed on condensed 
milk and recently had had crackers in addition. She had 
never been ill, except for a mild attack of diarrhea a month 
before. She had always been backward, but her parents had 
not thought much of it until she was sixteen months old. 
She had never learned to sit up alone and could say but one 
or two words. She was usually quiet and good-natured, but 
moaned occasionally. She was seen when two years old. 

Physical Examination. She was fairly developed and 
nourished, but pale and flabby. Her expression was dull and 
stupid. She stared about without taking much notice, but 
could see and hear. She usually lay quietly, with the excep- 
tion of coarse movements of her arms and fingers. She 
apparently amused herself by making a peculiar sucking 
noise and frequently made grimaces by putting out her 
tongue and rolling up her eyes. Her cry was hoarse but she 
said nothing. Her head was of good shape. The fontanelles 
were closed. The circumference of the head was 45 cm. 
(normal is 48 cm.); that of the chest, 43 cm. (normal is 
51 cm.). Her hair was soft and fine. The palpebral openings 
were narrow and the eyes appeared deep-set. The outer 
canthi were slightly higher than the inner. The epicanthic 
folds were not marked. The pupils were equal and reacted 
to light. The nose was short and flat and wider than usual 
between the eyes. She had twelve teeth. Her tongue was 
somewhat enlarged, but moist and smooth. She kept it 
protruded beyond the lips most of the time. A moderate 
amount of adenoids was felt with the finger. The throat was 
otherwise normal. The neck was of normal length and there 
were no supraclavicular pads. The thyroid was of normal 
size. She was able to hold up her head, but not to sit alone. 
There was a marked curve of weakness. There was a slight 
rosary. The heart and lungs were normal. The abdomen 
was slightly enlarged, but otherwise normal. The liver and 
spleen were not palpable. The extremities were of normal 




Joseph C. Case 159. 




Helen T. Case 160. 



DISEASES OF THE NERVOUS SYSTEM. 5I9 

length, the distance from the anterior superior spine to the 
sole being forty-six per cent of the total length. The epiphyses 
at the ankles were slightly enlarged. The hands were of good 
shape, except that the little fingers curved in rather more 
than usual. She had no idea of standing up or what her legs 
were for. There was no spasm or paralysis. The knee-jerks 
were equal and normal. Kernig's sign was absent. There 
was no enlargement of the peripheral lymph nodes. The skin 
was normal. 

The urine was cloudy, straw-colored, acid in reaction, and 
contained neither albumin nor sugar. The sediment consisted 
of amorphous phosphates. 

Blood. 

Hemoglobin, 70% 

Red corpuscles, 5,192,000 

White corpuscles, 12,400 

Diagnosis. This child is, of course, an idiot. The history 
and the fact that she sees rule out amaurotic idiocy. The 
normal size and shape of the head exclude hydrocephalic and 
microcephalic idiocy. The absence of spasm, paralysis and 
exaggerated reflexes shows that there is no gross cerebral 
lesion, either congenital or as the result of hemorrhage at 
birth. The enlargement and protrusion of the tongue and the 
expression of the face suggest cretinism to a certain extent. 
This can be excluded, however, on the fineness of the hair, 
the normal condition of the skin, the absence of supraclavicu- 
lar pads, the normal length of the neck and of the extremities 
and the normal shape of the hands and feet. There are many 
points about the physical examination which are in favor of 
the Mongolian type of idiocy. These are the hoarse cry, 
the narrow palpebral openings, the obliqueness of the eyes, 
the distance between the eyes, the short and flat nose, the 
enlargement of the tongue and the incurvation of the little 
fingers. The incurvation of the little fingers is so common 
however, even in normal persons, that it is of little importance. 
It is true that the back of the head is of good shape, that the 
epicanthic folds are not marked, that the angle of the eye 
is but very little increased and that the tongue is not dry and 



520 CASE HISTORIES IN PEDIATRICS. 

fissured. Marked changes in the tongue almost never develop 
as early as two years, however, and the head is not always 
flattened anteroposteriorly in Mongolian idiocy. The angle 
of the eyes and the development of the epicanthic folds are 
merely questions of degree. The diagnosis of Mongolian 
Idiocy is, therefore, justified. 

Prognosis. Mongolian idiots are extremely susceptible to 
infection and resist disease very badly. She will probably, 
therefore, not live many years. There is no prospect that she 
will become a useful member of society or able to support 
herself. She will probably be able to walk and can probably 
be taught to feed herself and be cleanly in her habits. Little 
more than this can be expected. 

Treatment. She should be placed in some institution for 
the feeble-minded, because children are better taught and 
better cared for in such institutions than at home and be- 
cause, when in an institution, they do not serve as bad 
examples to other children. 



DISEASES OF THE NERVOUS SYSTEM. 521 

CASE i6i. John D. was the eighth child of healthy 
parents. There had been no deaths or miscarriages. He was 
born at full term after a very difficult labor in which his head 
was much bruised and the left clavicle broken. His head was 
much misshapen at birth, but when he was a month old seemed 
perfectly normal. His mother noticed when he was two 
months old that his head was becoming larger. She thought 
that it had increased in size very rapidly during the last week. 
When he was two and one-half months old she noticed that 
the eyes "dropped down" and that he did not close the lids 
when he was asleep. She said that he moved his extremities 
normally, but that he was quieter than her other babies had 
been. He rarely cried and took but little notice. In fact, 
she was not sure that he could see. He was entirely breast- 
fed, had had no disturbance of digestion and had gained 
steadily in weight. He was seen in consultation when three 
months old. 

Physical Examination. He was well developed and nour- 
ished and of good color. The head was much and symmetri- 
cally enlarged. The anterior fontanelle was six cm. in diam- 
eter and bulging, while the posterior fontanelle was two cm. 
in diameter. The saggital, coronal, frontal and lambdoid 
sutures were open. The occipito-frontal circumference of the 
head was forty-six cm. (average is 39.5 cm.). The superficial 
veins of the scalp were much enlarged. The forehead was 
very prominent and the face appeared small. He could not 
close his eyelids and a quarter of an inch of conjunctiva was 
visible above the iris when the eyes were open. The pupils 
were equal and reacted to light. He both saw and heard. 
There was no spasm or paralysis of any of the muscles sup- 
plied by the cranial nerves. There was no nasal discharge 
and he kept his mouth shut. The heart, lungs, abdomen and 
genitals were normal. There was no rosary. The circum- 
ference of the chest at the nipples was thirty-nine cm. (aver- 
age is 38 cm.). The lower border of the liver was palpable 
two cm. below the costal border in the nipple line. The 
spleen was not palpable. The extremities were normal. 
There was no spasm or paralysis. The knee-jerks were equal 
and normal. Kemig's sign was absent. There was no 



522 CASE HISTORIES IN PEDIATRICS. 

enlargement of the peripheral lymph nodes. There was no 
eruption and there were no scars of any old eruption. There 
were no mucous patches or rhagades about the mouth or 
anus. 

Diagnosis. There can be no doubt, of course, that the 
trouble is Congenital Chronic Internal Hydrocephalus. 
Rachitic enlargement of the head, the only condition with 
which it could be confused, can be excluded on the age of the 
baby, the symmetry of the head, the bulging of the fontanelle, 
the open sutures, the enlargement of the veins of the scalp, 
the pushing down of the eyes and the absence of all other 
signs of rickets. The absence of spasm, paralysis, exaggera- 
tion of the deep reflexes and Kernig's sign is presumably due 
to the relatively slow accumulation of the fluid, the brain 
having had time to accommodate itself to the gradual in- 
crease in the pressure. Syphilis can be excluded as the cause 
of the hydrocephalus in this instance on the good family 
history and the absence of all signs of syphilis. The etiology 
is, therefore, as in most such cases, entirely obscure. 

Prognosis. The prognosis is practically hopeless. The 
head will almost certainly increase steadily in size and death 
ensue in a few months. It is barely possible, however, that 
the process will, after a time, cease. If it does, he will in all 
probability be more or less deficient mentally and probably 
be partially paralyzed. There is a small chance, however, 
that he may be normal both mentally and physically, except 
for a large head. There is no possibility of a diminution in 
the size of the head, even if the process ceases and he survives. 

Treatment. It being possible to exclude syphilis as the 
etiological factor in this case, nothing whatever can be 
accomplished by medicinal treatment. The removal of the 
fluid by lumbar puncture or by tapping the lateral ventricles 
is a useless procedure, because it does not remove the cause 
of the trouble and the fluid consequently quickly reaccumu- 
lates. The injection of astringent solutions into the lateral 
ventricles is open to the same objection. Draining the 
cerebrospinal fluid into the peritoneal cavity through a 
trephine opening in a lumbar vertebra is a simple operation 
and temporarily effective. Unfortunately, the opening is 



DISEASES OF THE NERVOUS SYSTEM. 523 

always soon closed by adhesions or the overgrowth of granu- 
lation tissue, even when a silver tube is used. Various 
operations, the object of which is to drain the fluid from the 
lateral ventricles into the subarachnoid space, one of the 
cerebral sinuses or a vein in the neck, are possible. They are 
all open to the same objection and that is, that unless the 
connection is made through some normal channel, like a 
transplanted vein or artery, Nature quickly heals the wound 
and stops the drainage. If a transplanted vessel is used to 
make the connection there is, however, a reasonable chance 
of permanent cure. All these operations are, of course, 
extremely dangerous. This baby can see and hear, and has 
no spasm or paralysis. If the process can be stopped now 
and further increase of intracranial pressure prevented, he 
will almost certainly develop normally both physically and 
mentally. He is in good general condition and a good 
operative risk. He is practically certain to die if he is not 
operated upon or, if he does not, to be a paralytic imbecile. 
It seems justifiable, therefore, to advise an operation for 
permanent drainage through a transplanted vessel, provided 
a surgeon competent to perform the operation is available, 
although the chances are that he will die during or as the 
result of the operation. 



524 CASE HISTORIES IN PEDIATRICS. 

CASE 162. Joseph K. was the second child of healthy 
parents. The other child was well and there had been no 
miscarriages. He was born at full term, after a normal labor, 
and was normal at birth. He was breast-fed, gained rapidly 
in weight and developed normally until he was nine months 
old, when he had an attack of cerebrospinal meningitis. 
The parents thought that he had been blind and deaf since 
this illness, and had noticed that his head had increased 
rapidly in size during the past month. He took the breast 
well and had no disturbance of digestion. He was brought 
to the Infants' Hospital, when he was eleven ijionths old, 
because of the blindness, deafness and enlargement of the 
head. 

Physical Examination. He was well developed and nour- 
ished and of fair color. His head was somewhat enlarged, 
the occipito-frontal circumference being forty-eight cm. 
(average is 45 cm.). The enlargement was symmetrical. 
The anterior fontanelle was four and one-half cm. in diam- 
eter and bulging. The posterior fontanelle and sutures were 
closed. He was able to hold up his head, but rather feebly. 
He could not sit alone. The conjunctivae were not visible 
above the irides. The pupils were equal and reacted to 
light. He could not see and probably could not hear. The 
fundi were normal. There was no spasm or paralysis of any 
of the muscles supplied by the cranial nerves. He had six 
teeth. There was no rigidity of the neck and no neck sign. 
There was a very slight rosary. The circumference of the 
chest at the nipples was forty-four cm. (average is 45 cm.). 
The heart, lungs, abdomen and genitals were normal. The 
lower border of the liver was palpable two cm. below the costal 
border in the nipple line. The spleen was not palpable. 
The extremities were normal. There was no paralysis of the 
extremities, but there was a little spasm in the legs. There 
was a tendency to keep the legs crossed. The knee-jerks 
were equal, but much exaggerated. There was at times a 
marked ankle clonus on the right. Kernig's sign was marked 
on the right, slight on the left. There was no enlargement 
of the superficial lymph nodes. The rectal temperature was 
98.6° F,; the pulse, 120; the respiration, 30. 



DISEASES OF THE NERVOUS SYSTEM. 525 

Lumbar puncture was done and forty cc. of perfectly clear 
fluid under somewhat increased pressure allowed to run off. 
The level of the fontanelle was then that of the surrounding 
bones. This fluid contained about tV% of albumin and did 
not deposit a fibrin clot. 

Diagnosis. The enlargement of the head and the bulging 
of the anterior fontanelle show that there is an increase in the 
intracranial pressure. This is proved by the fact that when 
lumbar puncture was done the cerebrospinal fluid ran off 
under increased pressure. The absence of changes in the 
optic nerves, the normal position of the eyes and the closed 
sutures show that this pressure is not extreme. The fact 
that the sutures are closed is of comparatively little impor- 
tance, however, because they are often fairly firmly united at 
nine months. When it is taken into consideration that this 
increased cerebral pressure followed an attack of cerebro- 
spinal meningitis, there can be no doubt that it is due to an 
Acquired Internal Hydrocephalus as the result of this 
disease. The hydrocephalus in this instance cannot be due 
to obstruction of any of the foramina, because the fluid ran 
off freely on lumbar puncture. It must be due, therefore, 
either to some obstruction to the veins of Galen or to some 
pathological change in the choroid plexus. The absence of 
a fibrin clot and of an increased percentage of albumin in the 
cerebrospinal fluid shows that there is no inflammation at 
present. The increase in the cerebral pressure does not seem 
sufficient to account for the blindness and probable deafness. 
These are almost certainly due to degenerative changes in 
the nerves resulting from the cerebrospinal meningitis. The 
spasm of the legs, the tendency to keep the legs crossed, 
the exaggeration of the knee-jerks, the ankle clonus and the 
Kernig's sign may be due to cerebral irritation from the in- 
creased intracranial pressure, but are more probably due to 
meningeal or cortical changes caused by the meningitis. 

Prognosis. The blindness and deafness are, of course, 
irremediable. The spasm of the extremities, being in all 
probability due to lesions of the cortex or meninges, will 
persist. These lesions are very likely, moreover, to be the 
cause of convulsions in the future. There is a reasonable 



526 CASE HISTORIES IN PEDIATRICS. 

chance that the hydrocephalus may not increase or may, 
perhaps, even diminish, as the result of the absorption or 
contraction of the inflammatory tissue which is causing the 
obstruction to the circulation. 

Treatment. There is no medicinal treatment which can 
hasten the resolution of the newly formed tissue, which is 
the cause of the hydrocephalus. It is possible, however, that 
the withdrawal of the fluid by lumbar puncture may, by 
diminishing the intracranial pressure, favor resolution. It 
seems rational, therefore, to do this and to repeat the opera- 
tion as often as is necessary to keep down the pressure. If 
there is no improvement after repeated punctures it will then 
be time to consider the advisability of some operation to 
establish permanent drainage (see Case i6i). It seems 
hardly worth while to attempt this, however, when it is 
taken into consideration that the baby is blind and deaf and 
has a spastic paraplegia. 



DISEASES OF THE NERVOUS SYSTEM. 527 

CASE 163. Marion S. was the first child of young and 
unusually vigorous parents. There had been no previous 
miscarriages. She was delivered at full term by low forceps 
and weighed six and one-half pounds. She was very feeble 
at first, but rallied after twenty-four hours. The breast-milk 
gave out after three days and she was given a strong modified 
milk. She did not vomit, but the bowels were constipated 
and she did not gain in weight. She began to vomit, however, 
when four weeks old. The vomiting was at first more like 
regurgitation and always occurred in the first hour after 
feeding. A wet-nurse was procured two days later. She 
would not take the breast and consequently was given two 
ounces of breast-milk with one teaspoonful of water every 
two and one-half hours. The vomiting continued, neverthe- 
less, soon became explosive in character, and was at times 
apparently accompanied by pain. The constipation became 
more marked, movements being obtained only by enemata. 
These were very small, brownish-green in color and sticky in 
consistency. She had had only whey and water during the 
last twenty-four hours. The water had been retained; the 
whey, however, had been vomited immediately or, if not, 
retained for two or three feedings and then vomited. She 
had lost weight and strength very rapidly during the last 
week. The physician who had had charge of the baby up to 
twenty-four hours before she was seen in consultation, when 
six weeks old, had said that she was normal at birth, and had 
either not noticed or had not said anything about the con- 
dition of the fontanelle. The mother, however, thought that 
the fontanelle had always been a little full. Divergent 
strabismus was noticed the day before she was seen. 

Physical Examination. She was small and thin, but of 
fair color. She was evidently uncomfortable and cried out 
frequently. Her condition was so serious that careful meas- 
urements of the head and chest were not made. The head 
was, however, large when compared with the chest. The 
enlargement was symmetrical. The forehead was somewhat 
prominent. The anterior fontanelle was about four cm. in 
diameter and bulging. The posterior and lateral fontanelles 
were open, the posterior fontanelle being two cm. in diam- 



528 CASE HISTORIES IN PEDIATRICS. 

eter. The sagittal, coronal, frontal and lambdoid sutures 
were open. The conjunctivae were not visible above the 
irides and the eyelids closed normally. There was no stra- 
bismus. The pupils were equal and reacted to light. There 
was no nasal discharge. There was no rigidity of the neck or 
neck sign. The heart and lungs were normal. The level of 
the abdomen was that of the thorax. There was no visible 
peristalsis over the stomach, and no tumor in the region of 
the pylorus was felt. The liver was palpable two cm. below 
the costal border in the nipple line. The spleen was not 
palpable. The extremities were normal. There was no 
spasm or paralysis. The knee-jerks were equal, but exagger- 
ated. There was a slight Kernig's sign on both sides. There 
was no enlargement of the peripheral lymph nodes. There 
was no eruption and there were no scars of old eruptions. 
There were no mucous patches about the mouth or anus. 
The rectal temperature was 98° F. ; the pulse, 140; the respi- 
ration, 25. She weighed five pounds. 

Diagnosis. The vomiting, constipation and loss of weight 
seem at first to point directly to some disease of the stomach. 
The explosive character of the vomiting, the fact that the 
vomiting has increased in spite of the change to human milk 
and the meconium-like stools suggest that it is stenosis of 
the pylorus. The divergent strabismus and the fullness of 
the fontanelle point, however, to some trouble in the head. 
When this possibility is taken into consideration, it is evident 
that the continued vomiting and its explosive character may 
be equally well explained by an increase in the intracranial 
pressure. The symmetrical increase in the size of the head, 
the prominence of the forehead, the open fontanelles and 
sutures and the bulging of the anterior fontanelle are all 
evidences of an increase in the intracranial pressure. The 
only chronic condition which can cause such a marked 
increase in pressure at this age is Congenital Internal 
Hydrocephalus. The exaggeration of the knee-jerks and 
the positive Kernig's sign are further evidences of cerebral 
disease. The evidence in favor of the brain as the location 
of the trouble is so strong that it hardly seems necessary to 
mention that the absence of visible gastric peristalsis and of 



DISEASES OF THE NERVOUS SYSTEM. 529 

a palpable tumor at the pylorus counts very strongly against 
stenosis of the pylorus. Syphilis can be excluded as the 
cause of the hydrocephalus in this instance on the good family 
history, the fact that the baby was born at full term and the 
absence of all signs of syphilis. The etiology is, therefore, 
as in most such cases, entirely obscure. 

Prognosis. The prognosis is practically hopeless. The 
increase in the intracranial pressure will almost certainly 
continue and the head steadily increase in size. She will 
probably not live more than a few days, or at most a few 
weeks. It is barely possible, however, that the pressure will 
after a time cease. If it does, she w^ill, in all probability, be 
more or less deficient mentally and partially paralyzed. 

Treatment. It being possible to exclude syphilis as the 
etiological factor in this instance, nothing whatever can be 
accomplished by medicinal treatment. The various opera- 
tive procedures which may be employed in the treatment of 
chronic internal hydrocephalus are described in Case i6i. 
It is obvious that the baby's general condition is at present 
too poor to warrant any serious operation. Lumbar puncture 
ought to be done, however, to diminish the intracranial 
pressure. It is not likely to do any permanent good, but will 
almost certainly diminish the discomfort and perhaps stop 
the vomiting. It may be repeated as often as is necessary 
to keep down the intracranial pressure. She should be given 
half an ounce of whey every hour. If this is retained, human 
milk, with 25% of lime water, half an ounce to one ounce 
every two hours, should be tried 



530 CASE HISTORIES IN PEDIATRICS. 

CASE 164. Jacob A. was the child of healthy parents. 
One other child was well, two had died of *' summer com- 
plaint " and three of diphtheria. There had been no mis- 
carriages. 

He was fed from birth on a mixture of three parts of whole 
milk and one of water. When five months old he was given 
tea and crackers, and probably other things also, in addition. 
He had always done well, had not vomited and had had nor- 
mal movements. He began to cry almost constantly October 
20. Swelling of the arms and legs appeared at the same time. 
He was seen October 22, when ten months old. 

Physical Examination. He was well developed and nour- 
ished, but rather pale. He was perfectly conscious. The 
parietal and frontal eminences were moderately enlarged, and 
the head was somewhat flattened on top. The anterior fon- 
tanelle was 4 cm . in diameter and level. The pupils were 
equal and reacted to light. There was no craniotabes. He 
had two teeth. The gums, mouth and throat were normal. 
The tongue was clean. The ear-drums were normal. There 
was a moderate rosary. The heart and lungs were normal. 
The level of the abdomen was somewhat below that of the 
thorax, but nothing abnormal was detected in it. The liver 
was palpable 2 cm. below the costal border in the nipple line. 
The spleen was not palpable. The epiphyses at the wrists 
were slightly enlarged. There was a rather tense swelling of 
the feet and legs half-way to the knees, and of the hands and 
lower halves of the forearms. This swelling was not hot, 
tender or red. It did not pit on pressure. He held his arms 
partly flexed at the elbows and at the wrists. The hands were 
turned a little to the ulnar side. The fingers and thumbs were 
flexed sharply at the metacarpo-phalangeal joints and ex- 
tended at the phalangeal joints, the thumb being inside the 
fingers. The legs were held partially flexed at the knees and 
partially extended at the ankles, with flexion of the toes at 
the metatarso-phalangeal and extension at the phalangeal 
joints. Any attempt to overcome the spasm in the arms and 
legs caused much pain. The knee-jerks could not be tested 
because of the spasm. Kernig*s sign was absent. The facial 
phenomenon was absent. Trousseau's symptom could not 




Hydrocephali 




Deformity of head and chest in Rickets. 



DISEASES OF THE NERVOUS SYSTEM. 531 

be tested because of the spasm. There was a slight general 
enlargement of the peripheral lymph nodes. The rectal 
temperature was ioi° F., the pulse no, the respiration 40. 
A few minutes after the examination he became entirely 
relaxed. The spasm returned again, however, in a short 
time. 

The urine was pale, clear, acid in reaction, of a specific 
gravity of 1,010, and contained neither albumin nor sugar. 

Diagnosis. Tetanus can be ruled out on the absence of 
trismus and the characteristic position of the extremities. 
Meningitis can be excluded on the normal mental state, the 
level fontanelle, the absence of involvement of the cranial 
nerves and of rigidity of the neck and the characteristic 
position of the extremities. The age of the baby, the good 
general condition, the intermittence of the paroxysms, the 
pain in association with them and the swelling of the extremi- 
ties are all characteristic of tetany. The position of the 
extremities during the spasm is pathognomonic of Tetany 
and makes the diagnosis positive. The swelling of the extrem- 
ities is undoubtedly nervous in origin and belongs in the class 
of the angioneurotic edemas. The enlargement of the frontal 
and parietal eminences, the flattening of the top of the head, 
the rosary and the enlargement of the epiphyses at the wrists 
are signs of rickets, as is probably the delayed dentition. 

Tetany is not properly'^a disease but merely a manifestation 
of the spasmophilic diathesis. In this condition there is a 
marked increase in the nervous excitability, which shows 
itself in various ways, the most characteristic manifestations 
being laryngismus stridulus, tetany and convulsions. The 
spasmophilic diathesis is almost certainly due to some dis- 
turbance in the metabolism of calcium. It is uncertain 
whether this disturbance is or is not due to parathyroid 
insufficiency. There is in all probability a deficiency of cal- 
cium salts in the blood in the spasmophilic diathesis. His 
diet, which has been largely made up of cow's milk has never 
been deficient in calcium. The calcium in cow's milk is, how- 
ever, not nearly as well utilized as that in human milk, so 
that he may well not have absorbed a sufficient amount. 
The rickets is, therefore, merely another manifestation of 



532 CASE HISTORIES IN PEDIATRICS. 

disturbance of nutrition and not the cause of the paroxysmal 
contractions. 

Prognosis. The prognosis depends very largely on whether 
or not he can get the best treatment. If he can, the paroxysms 
will quickly cease. If he cannot, they will probably continue 
and other manifestations of the spasmophilic diathesis are 
very likely to develop. There is no danger of death in a 
paroxysm of tetany, but he may die in an attack of laryngis- 
mus stridulus or during a convulsion. 

Treatment. No treatment is necessary for the paroxysms 
unless they are more severe than at present. A bath at iio° F. 
is the best treatment. If the attacks become more severe, they 
can be controlled to a certain extent by bromide of sodium or 
potassium, in doses of from three to five grains, in an aqueous 
solution, given three or four times daily. The attacks will be 
less likely to develop if he is kept quiet and not disturbed. 

The treatment of the spasmophilic diathesis consists in 
regulation of the diet. Human milk always quickly relieves 
this condition. A purely carbohydrate diet relieves it, but 
much less promptly and is, moreover, unsuitable for a baby 
of this age. A return to cow's milk in any form, at any rate 
until a considerable time has elapsed, almost invariably 
causes a return of the symptoms. The only rational food for 
this baby is, therefore, human milk. If he cannot get it, he 
must be given a starch and sugar solution for as long a time as 
is possible, due regard being paid to his general condition, and 
then gradually worked on to some modification of cow's milk. 

It is possible that the administration of some of the 
calcium salts, like the lactate, may do good. Dessicated 
calcium chloride, in doses of ten grains, six or seven times 
daily, has been highly recommended. The indications are 
so doubtful and the results obtained from the calcium salts 
have been so conflicting, however, that they are hardly 
worthy of consideration in comparison with human milk. 
Parathyroid extract, in doses of one-twentieth of a grain, or 
more, three times daily, would seem a more rational treat- 
ment. The results obtained with it thus far, however, have 
not been encouraging. 



DISEASES OF THE NERVOUS SYSTEM. 533 

CASE 1 65. Baby T. was born at full term after a normal 
first pregnancy. The membranes ruptured January ii and 
much liquor amnil drained away. Labor began the afternoon 
of January 12. The pains were hard, but very little progress 
was made. He was finally delivered by high forceps, after a 
manual dilatation, at 3 a.m., January 13. The operation was 
an easy one and did not take over an hour. The head was 
considerably compressed at birth but the fontanelles did not 
bulge. He weighed six and one-half pounds and seemed all 
right in every way. He cried normally and passed both urine 
and feces. He was not put to the breast but took water well. 

He suddenly stopped breathing and became deeply cya- 
notic at 8 P.M., January 13, seventeen hours after birth. He 
was brought around by artificial respiration, but had another 
similar attack about 9 p.m., which also required artificial 
respiration. He had breathed quietly and normally since 
then, but had not moved much and had not opened his eyes. 
A little twitching of the face was noticed during the morning 
of the 14th, and during the afternoon he moved his left arm 
constantly, but had no rigidity or convulsions. He took a 
little sugar and water^during the day and passed both urine 
and feces. J He became more stupid during the evening and 
could not be made to swallow. The pulse gradually fell 
during the day from 160 to 120. The rectal temperature 
varied between 99° F. and 99.5° F. He was seen in consulta- 
tion at 10.30 p.m., January 14. 

Physical Examination. He was well developed and nour- 
ished, and of good color. He could not be roused or made to 
move. His neck was flaccid. The head was of good shape 
and of normal size. The anterior fontanelle was 3 cm. and 
the posterior fontanelle 2 cm. in diameter. Both bulged a 
little. The sagittal and coronal sutures were i| cm. wide and 
a little full; the other sutures were closed. The axes of the 
eyes were parallel. The pupils were a little smaller than a 
pinhead and did not react to light. A little dried blood was 
seen high up in the nostrils. The mouth and throat were 
normal. There was no facial paralysis and no marks of the 
forceps. The heart, lungs and abdomen were normal. The 
cord was healthy. The liver was palpable i cm. below the 



534 CASE HISTORIES IN PEDIATRICS. 

costal border in the nipple line. The spleen was not palpable. 
The arms were held slightly flexed at the elbows and the 
hands were clenched. The spasm was, however, very easily 
overcome. There was no spasm of the legs. The knee-jerks 
were not obtained. There was no Kernig's sign. The rectal 
temperature was 99.5° F., the pulse 140, the respiration 24. 

Diagnosis. The diagnosis lies between some cerebral 
lesion, intestinal toxemia and sepsis. The facts that he has 
had no food, that his bowels have moved freely and that his 
temperature is practically normal are sufficient, in connection 
with the positive signs of cerebral trouble, to exclude intes- 
tinal toxemia. The normal condition of the cord, the normal 
temperature and the absence of any local manifestations of 
sepsis rule out sepsis. 

The age, lack of exposure and normal temperature exclude 
meningitis. The bulging of the fontanelles and sutures 
shows positively that there is an increase in the cerebral 
pressure. This was not present at birth. An internal hydro- 
cephalus could hardly have developed in seventeen hours. 
Serous meningitis does not develop without a cause and is 
usually accompanied by fever. The only reasonable ex- 
planation for the increased cerebral pressure is, therefore, a 
hemorrhage. The gradual development of the symptoms of 
increased cerebral pressure is perfectly consistent with a slow 
capillary oozing, which is the usual form of hemorrhage occur- 
ring at or soon after birth. The presence of blood high up in 
the nostrils is almost pathognomonic of cerebral hem.orhage, 
the blood coming through the cribriform plate. The diag- 
nosis of Cerebral Hemorrhage is, therefore, justified. The 
diagnosis is so certain that it hardly seems necessary to do a 
lumbar puncture to confirm it. The spinal fluid does not 
always contain blood, moreover, when there is a cerebral 
hemorrhage, and the presence of blood does not always indi- 
cate cerebral hemorrhage, because it may be due to the wound- 
ing of some vessel during the puncture. The fact that the 
involuntary motions were confined to the left arm suggests 
that the hemorrhage is greater on the right than on the left 
side of the brain. This point is not of much importance, 
however, because, owing to the imperfect development of 



DISEASES OF THE NERVOUS SYSTEM. 535 

the cortical centers and the general nervous excitability at 
this age, no very definite conclusions can be drawn from what 
would be important localizing symptoms in an older child or 
an adult. 

Prognosis. He is almost certain to die if he is not operated 
upon. If he does not die, he will surely be paralyzed and 
probably feeble-minded. He will probably die during or soon 
after the operation. If he does not, he may still be paralyzed, 
but the paralysis will be less extensive than it will be if he is 
not operated upon. There is a reasonable chance, however, 
that the operation will relieve the symptoms and that he will 
develop normally. 

Treatment. He should be operated on immediately. 
Delay will mean still further hemorrhage and more pressure 
on and damage to the brain. 



536 CASE HISTORIES IN PEDIATRICS. 

CASE i66. Elsie L., two and one-fourth years old, was 
the first child of healthy parents. There had been no mis- 
carriages. She was born after a very difficult instrumental 
vertex delivery at the end of a long labor and was almost dead 
at birth. She was not nursed, as she was too weak to take 
the breast. She did not thrive during infancy, but since then 
her general condition had been good. She had had no con- 
vulsions. She sat up alone at nine months and cut her first 
tooth at a year. She began to stand at sixteen months, but 
did not begin to walk at all until she was twenty-six months 
old. Her gait was then noticed to be very peculiar. She was 
brought because she did not walk well. She used her hands 
well, talked early and was bright mentally. She controlled 
the sphincters of the bladder and anus. 

Physical Examination. She was well developed and nour- 
ished and of good color. Her tongue was clean and her mouth 
and throat normal. There was no rosary. The heart, lungs 
and abdomen were normal. The liver and spleen were not 
palpable. She talked well for a child of her age and seemed 
bright. There was no spasm or paralysis of any of the muscles 
supplied by the cranial nerves. There was no deformity of 
the spine, and it was normally flexible. There was no paraly- 
sis or spasm of the arms, and the reflexes of the arms were 
normal. She stood with her knees close together, her body 
flexed on the thighs, the knees partially flexed and the heels 
a little off the ground. When she walked the knees rubbed 
together and one leg crossed in front of the other. When 
lying down the legs could be straightened on the thighs and 
the feet brought to a right angle, but with some little diffi- 
culty. Separation of the legs was resisted and was impossible 
to more than a moderate extent. There was decided resist- 
ance to hyperextension of the thighs. The knee-jerks were 
equal, but much exaggerated. There was no ankle clonus. 
The sensation was normal. The legs were warm, of good 
color and not wasted. Kernig's sign was absent. Babinski*s 
phenomenon was present on both sides. There was no en- 
largement of the peripheral lymph nodes. 

Diagnosis. This little girl has a paraplegia with spasm. 
The spasm, exaggeration of the reflexes and normal sensation 



DISEASES OF THE NERVOUS SYSTEM. 537 

rule out any lesion of the peripheral nerves. The spasm, 
exaggeration of the reflexes and absence of wasting rule out a 
lesion of the anterior horns, such as occurs in anterior polio- 
myelitis. Transverse myelitis, except from disease of the 
spine, almost never occurs at this age. There is no deformity 
of the spine in this instance and it is normally flexible. Trans- 
verse myelitis from other causes can be excluded on its rarity 
at this age and the absence of loss of control of the sphincters 
and of disturbance of sensation. The lesion must, therefore, 
be in the brain. It is hard to conceive of a lesion anywhere 
in the brain which would cause a spastic paraplegia without 
other symptoms, except in the cortex. A lesion of the cortex 
in the region of the upper portion of the post-central convolu- 
tion on both sides of the longitudinal fissure would cause just 
such a combination. Such a lesion in an infant is [usually a 
congenital defect or the result of a subdural [hemorrhage at 
birth. The long, hard labor, which is the usual cause of such 
hemorrhages at birth, and her feeble condition after birth, 
make it almost certain that in this instance the lesion is due 
to a hemorrhage at birth. The diagnosis of Cerebral 
Paralysis resulting from a subdural hemorrhage at birth is, 
therefore, justified. 

Prognosis. There will be no extension of the paralysis and 
her mental development will be normal. There will be no 
spontaneous improvement in the condition of the legs. Much 
improvement in her walking can be expected, however, 
from suitable operations and apparatus. 

Treatment. Electricity and massage are useless in this 
condition because there is no disturbance of the nutrition of 
the muscles. It is probable that passive motions, if thor- 
oughly carried out, will prevent further contractures, but it is 
very doubtful if they will diminish those now present. Proper 
operative procedures, perhaps followed by the application of 
apparatus, ought to improve the position of her legs and make 
walking much easier. Resection of the posterior nerve roots, 
recently recommended for the relief of this condition, has not 
as yet been tried out thoroughly enough to justify its use, 
except as a last resort. She should be placed in the hands of 
an orthopedic surgeon for treatment. 



538 CASE HISTORIES IN PEDIATRICS. 

CASE 167. John J., nine months old, was the third child 
of healthy parents. There had been no deaths or miscar- 
riages. There v/as no tuberculosis in either family and there 
had been no known exposure to it. He had been well, 
although bottle-fed, up to May 7, when he became feverish 
and began to cough. There was much mucus in his throat. 
A physician who saw him at the time said that he had broncho- 
pneumonia. The cough and fever diminished after a few 
days. He had several convulsions May 15, which were 
followed by marked rigidity and almost constant twitching. 
He became drowsy and refused to take his food. He did 
not vomit and was not constipated. He was admitted to 
the Infants' Hospital, May 16. 

Physical Examination. He was well developed and nour- 
ished and of good color. He was unconscious, but made 
frequent involuntary motions. The anterior fontanelle was 
three cm. in diameter and level. There was no rigidity of 
the neck. The neck sign could not be determined, because 
of the constant motion of the legs. The pupils were equal 
and somewhat dilated. They reacted feebly to light. The 
throat was slightly reddened, but otherwise normal. The 
ear-drums were normal. The heart was normal. The lungs 
were normal, except for an occasional moist rale in both 
lower backs. The abdomen showed nothing abnormal. 
The lower border of the liver was palpable one cm. below the 
costal border in the nipple line. The spleen was not palpable. 
There was slight spasm of the extremities, but no paralysis. 
The knee-jerks could not be determined, because of the con- 
tinuous motion. Kernig's sign was absent. There was no 
enlargement of the peripheral lymph nodes. The rectal tem- 
perature was 102.6° F,; the pulse, 140; the respiration, 50. 

The urine was clear, acid in reaction and contained no 
albumin. 

The leucocytes numbered 8,400. 

Diagnosis. The signs in the lungs are not sufficient to 
account for his condition. The unconsciousness, the dilated 
and feebly reacting pupils and the spasm of the extremities, 
together with the absence of signs of disease elsewhere, show 
that, in spite of the fact that there is no bulging of the anterior 



DISEASES OF THE NERVOUS SYSTEM. 539 

fontanelle, the disease is in all probability located in the head. 
The absence of rigidity of the neck and of Kernig's sign count 
less against it than does the absence of bulging of the anterior 
fontanelle. If the disease is located in the head, it is pre- 
sumably some form of meningitis. The absence of leucocy- 
tosis counts strongly against all forms of meningitis, except 
the tubercular and the influenzal. The onset of the symptoms 
in the course of a catarrhal process in the throat and of 
bronchitis suggests that the trouble may be influenzal. This 
is a relatively rare condition, however, while tubercular 
meningitis is very common. The chances are, therefore, in 
favor of tubercular meningitis. The diagnosis can be made, 
however, only by lumbar puncture. 

Lumbar puncture was done and three cc. of very turbid 
fluid, under low pressure, were obtained. This fluid con- 
tained a large number of cells, 98% of which were polynuclear 
and 2% mononuclear. It also contained very many slender, 
Gram-negative bacilli, which stained deeply at the poles. 
The vast majority of these bacilli were outside of the cells. 

The characteristics of this fluid are the same as those of the 
cerebrospinal fluid in influenza meningitis, and the charac- 
teristics of the bacilli correspond in every way to those of 
the influenza bacillus. There can be no doubt, therefore, 
as to the diagnosis of Influenza Meningitis. 

Prognosis. The prognosis is practically hopeless. The 
course is almost invariably short in this form of meningitis. 
He will probably not live more than four or five days. 

Treatment. The treatment can be only symptomatic, as 
there is no serum readily available for this form of meningitis. 



540 CASE HISTORIES IN PEDIATRICS. 

CASE l68. Mary J., five months old, was the only child 
of healthy parents. She was breast-fed and had always been 
well. She was taken suddenly sick, April 6, with convul- 
sions, high fever, cough and labored breathing. She did not 
vomit. The bowels moved twice daily and the stools were 
normal. The cough, fever and labored breathing continued. 
She was admitted to the Infants' Hospital, April 9. 

Physical Examination. She was well developed and 
nourished, but moderately pale. She was stupid, but nursed 
fairly well. The respiration was grunting and accompanied 
by motion of the alae nasi. The anterior fontanelle was three 
cm. in diameter and level. There was no rigidity of the neck 
or neck sign. The pupils were equal and reacted to light. 
The ear-drums were normal. Nothing abnormal was de- 
tected in the chest. The abdomen showed nothing abnormal. 
The lower border of the liver was palpable two cm. below the 
costal border in the nipple line. The spleen was not palpable. 
There was no paralysis, but slight twitching and rigidity of 
the extremities. The knee-jerks were equal and exaggerated. 
Kernig's sign was absent. There was no enlargement of 
the peripheral lymph nodes. The rectal temperature was 
104° F. ; the pulse, 180; the respiration, 40. 

The urine was pale, slightly acid in reaction and contained 
a slight trace of albumin. The centrifugalized sediment 
showed only a few small and large round cells. 

The leucocytes numbered 48,000. 

Diagnosis. The sudden onset, the continued high tem- 
perature, the cough, the grunting respiration, the motion of 
the alae nasi and the leucocytosis are very characteristic of 
lobar pneumonia. The convulsions at the onset, the stupor 
and the slight twitching and rigidity of the extremities are 
not inconsistent with it. The absence of physical signs of 
pneumonia does not exclude it, because it is not uncommon 
to find no physical signs for several days after the onset in 
pneumonia at this age. The fact that the rate of the res- 
piration is not increased as much as that of the pulse suggests, 
however, that, in spite of the signs pointing to pneumonia, 
this may really not be the trouble, because the rate of the 
respiration is almost invariably increased out of proportion 



DISEASES OF THE NERVOUS SYSTEM. 54I 

to that of the pulse in this disease. The knee-jerks are, 
moreover, usually normal or diminished in pneumonia, not 
exaggerated, as in this instance. The convulsions at the 
onset, the stupor, the twitching and rigidity of the extremities 
and the exaggeration of the knee-jerks are all suggestive of 
some cerebral disease, either meningitis or encephalitis. 
They are suggestive enough to justify, or rather to demand, 
a lumbar puncture, because if there is a meningitis it is, 
judging from the acuteness of the onset and the leucocytosis, 
probably not tubercular but meningococcal. 

Lumbar puncture was done and five cc. of very turbid 
fluid, under low pressure, were obtained. This fluid de- 
posited a fibrin clot, but remained cloudy. A smear showed 
95% oi polynuclear and 5% of mononuclear cells. Very 
many Gram-staining diplococci were found, both within and 
without the cells. They were surrounded by a capsule, were 
pointed at the ends and showed a tendency to form chains. 
No cultures were made. 

There is, therefore, a Meningitis. It is, however, not 
due to the meningococcus, as was suspected, but to the 
Pneumococcus. The turbid fluid and the large excess of 
polynuclear cells are characteristic of this form of meningitis. 
Pneumococcus meningitis is very seldom a primary condition, 
but usually merely one of the manifestations of a general 
pneumococcus infection. It is very probable, therefore, that 
pneumonia may also develop in a few days. 

Prognosis. The prognosis is practically hopeless, as pneu- 
mococcus meningitis is almost invariably fatal. The course 
is usually short. She will almost certainly not live more 
than a week, probably less. 

Treatment. The treatment is essentially symptomatic. 
The organism should be typed, however, and, if the specific 
serum is available, it should be used as in meningococcus 
meningitis. Little can be hoped from it, however, as the 
results obtained with the pneumococcic sera in meningitis 
have been most discouraging. 



542 CASE HISTORIES IN PEDIATRICS. 

CASE 169. Frank F., eleven months old, was the only 
child -of healthy parents. He was nursed and had always 
been perfectly well. He was taken suddenly ill with pneu- 
monia of the right lower lobe, January 10. The tempera- 
ture ran between 103.5° F. and 104.5° F., his pulse between 
140 and 160, and his respiration about 60. He was quiet, 
but clear mentally, was able to nurse and had no disturbance 
of the digestion. He became very restless, January 16, and 
retraction of the neck and rigidity of the extremities devel- 
oped. He also had clonic spasms of the extremities from 
time to time. There was no change in the temperature, 
pulse and respiration. He was seen at the Infants' Hospital, 
January 17. 

Physical Examination. He was well developed and nour- 
ished. The cheeks were flushed and there was a tinge of 
cyanosis about the mouth. The respiration was grunting 
and the alae nasi moved with it. The neck was rigid and there 
was moderate opisthotonos. The neck sign could not be 
determined because of the rigidity of the neck. The anterior 
fontanelle was three cm. in diameter and bulged markedly. 
The membranae tympanorum were normaJ. There was 
bilateral internal strabismus. The right pupil was much 
dilated and neither reacted to light. He did not notice. 
There was no rosary. The heart was normal, except that 
the second sound at the pulmonic area was accentuated. 
There was flatness, loud bronchial respiration, increased vocal 
resonance and tactile fremitus, with an occasional high- 
pitched, moist rale, over the right lower lobe. The rest of 
the lungs was normal. The abdomen was normal. The 
liver was palpable two cm. below the costal border in the 
nipple line. The spleen was not palpable. There was 
constant twitching of the extremities, which were rigid. The 
knee-jerks were equal and much exaggerated. Kernig's sign 
could not be determined, because of the rigidity. The 
superficial lymph nodes were not palpable and there was 
no evidence of enlargement of the bronchial lymph nodes. 
The rectal temperature was 104.6° F.; the pulse, 180; the 
respiration, 64. 

The urine was high in color, acid in reaction, of a specific 
gravity of 1,020 and contained no albumin. 



DISEASES OF THE NERVOUS SYSTEM. 543 

The leucocytes numbered 36,000. 

Lumbar puncture was done and sixty cc. of clear fluid, 
under very high pressure, were allowed to run off. This fluid 
contained but six cells to the cubic millimeter and did not 
deposit a fibrin clot on standing. No organisms were found 
in the fluid and cultures from it were sterile. 

Diagnosis. The sudden onset of the symptoms of in- 
creased intracranial pressure and meningeal irritation in the 
course of a Pneumonia points strongly to a pneumococcus 
meningitis. The normal cerebrospinal fluid shows, however, 
chat this is not the case. It also excludes a complicating 
tubercular meningitis. The bulging fontanelle and the in- 
creased pressure under which the cerebrospinal fluid escaped 
when the lumbar puncture v/as done show, nevertheless, that 
there is an accumulation of fluid within the cranium. The 
absence of an excess of cells and of a fibrin clot in the cere- 
brospinal fluid proves that this accumulation of fluid is not 
due to an inflammatory process in the meninges. The most 
reasonable explanation is that it is due to increased secre- 
tion as the result of the irritation caused by the toxic prod- 
ucts of the pneumococcus in the blood. The condition is, 
therefore, the so-called Serous Meningitis. 

Prognosis. The outlook is very dark, because, although 
the intracranial pressure can be kept down by repeated 
lumbar punctures, it shows a degree of toxaemia which of 
itself is almost certain to prove fatal. The point most in his 
favor is that, this being the seventh day of the pneumonia, 
the crisis may be expected at any time. 

Treatment. Nothing can be done to diminish the secretion 
of cerebrospinal fluid. It can, however, be removed by 
lumbar puncture as fast as it is formed. Lumbar puncture 
should be done, therefore, as soon as there is much bulging 
of the fontanelle and the fluid drawn off until the fontanelle 
is depressed, even if the operation has to be repeated every 
few hours. The further treatment is that of pneumonia in 
general. (See Cases 113 and 114.) 



544 CASE HISTORIES IN PEDIATRICS. 

CASE 170. Robert K., two and three-fourths years old, 
was the child of healthy parents. One brother was alive and 
well, another had died at birth. There had been no mis- 
carriages. There was no tuberculosis in the family and there 
had been no known exposure to tuberculosis. He was born 
at full term after a normal labor and was normal at birth. He 
was nursed for eleven months. He had always been well, 
except for measles a year before and frequent colds with 
bronchitis. 

He fell down stairs, striking his head, early in the morning 
of August 3. He was apparently not hurt and appeared well 
all day. He began to vomit during the morning of August 4 
and continued to vomit, at intervals of about an hour, until 
3 A.M., August 5. He did not vomit again. There had been 
no known indiscretion in diet and the bowels were open. He 
was delirious in the early morning. He was admitted to the 
Children's Hospital at 2 p.m., August 5. 

Physical Examination. He was well developed and nour- 
ished and of good color. He was restless and irrational but, 
when roused, noticed a little. There was no rigidity of the 
neck and no neck sign. The pupils were equal and reacted to 
light. The tongue was fairly clean. The throat, heart, 
lungs and abdomen were normal. The liver and spleen were 
not palpable. There was no spasm or paralysis. The knee- 
jerks were equal and normal. Kernig's and Babinski's signs 
were absent. There was no ankle clonus. The rectal tem- 
perature was 99.8° F., the pulse 120, the respiration 36. 

The urine was light yellow in color, clear, acid in reaction 
and contained no albumin, sugar or acetone. The sediment 
contained a few epithelial cells and crystals of uric acid. 

The fluid obtained by lumbar puncture was under con- 
siderable pressure. It ran clear at first, but the last of it was 
somewhat bloodstained. No fibrin clot formed in twenty- 
four hours. It contained 360 cells to the cubic millimeter, 
a part of which were undoubtedly due to the admixture of 
blood. The differential count of these cells, which showed 
90% of mononuclear to 10% of polynuclear, shows that 
only a few of them came from the blood, because, if many 
of them had come from the blood, the number of polynuclear 



DISEASES OF THE NERVOUS SYSTEM. 



545 



cells would have at least equaled that of the mononuclear. 
No tubercle bacilli or other organisms were seen on a routine 
examination, and cultures were sterile. 

He passed a very restless night and at times was quite 
noisy, requiring morphia to keep him quiet. He was quiet 



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Chart of Robert K. Case i70« 

and drowsy the morning of August 6. There was no rigidity 
of the neck or neck sign. The pupils were equal and reacted 
to light. The knee-jerks were equal and lively, the abdomi- 
nal and cremasteric reflexes normal. There was no Kernig's 
sign and no ankle clonus. 

He was quiet August 7. There was slight rigidity of the 
neck. The pupils were equal and reacted to light. The 



54^ CASE HISTORIES IN PEDIATRICS. 

knee-jerks were present and equal, but sluggish. There was 
a suggestion of Kernig's sign on the left but none on the right. 
Babinski's phenomenon was absent. 

He recognized and spoke to his parents and remembered 
the names of friends and relatives August 8. He noticed 
more and was afraid of the light used to test the reaction of 
the pupils. They were equal and reacted to light. There 
was no rigidity of the neck, and no neck sign. There was 
no spasm or paralysis. The knee-jerks were equal and 
normal. The abdominal and cremasteric reflexes were not 
obtained. Kernig's and Babinski's signs were absent. 
Sensation to touch and pain was normal. 

The white blood count was io,ioo. 

Another lumbar puncture was done. The fluid was clear 
and contained 480 cells to the cubic millimeter, 97% of 
which were small mononuclear. Many of the cells were 
degenerated. No organisms were seen in a routine exami- 
nation, and cultures were sterile. 

He was seen at 10 a.m., August 8. 

Diagnosis. The positive findings in the cerebrospinal 
fluid show that the trouble is located in the central nervous 
system (see Case 38 for description of the normal cerebro- 
spinal fluid and of the fluid in meningitis). They exclude 
all forms of meningitis except the tubercular, but are also 
consistent with acute poliomyelo-encephalitis, in the acute 
stage of which the cerebrospinal fluid contains a considerable 
excess of cells, largely small mononuclear. The diagnosis 
lies, therefore, between tubercular meningitis and acute 
poliomyelo-encephalitis. If it is poliomyelo-encephalitis, 
the stress of the disease has fallen in this instance, of course, 
on the cerebrum, and it can be spoken of as an encephalitis. 

The absence of a family history of, or of exposure to, 
tuberculosis does not rule out tubercular meningitis; the 
history of an attack of measles in the past is a small point 
in its favor. The acuteness of the onset is somewhat in 
favor of encephalitis, but is not inconsistent with tubercular 
meningitis. The fall was probably purely a coincidence, 
but, in any case, is of no assistance in differential diagnosis 
as it might predispose to the development of either condi- 



DISEASES OF THE NERVOUS SYSTEM. 547 

tion. There is nothing about the symptomatology which 
is inconsistent with either condition, although the absence 
of the neck sign and the slightness of the changes in the 
reflexes and of the rigidity of the neck are somewhat against 
tubercular meningitis. The improvement in the symptoms 
and the drop in the temperature, while they suggest the 
beginning of convalescence from encephalitis, do not by 
any means exclude tubercular meningitis, because remissions 
are characteristic of this disease. The absence of leuco- 
cytosis is common to both diseases. The absence of a 
fibrin clot in the cerebrospinal fluid counts against tuber- 
cular meningitis; the absence of tubercle bacilli does not, 
because they are not found in more than ten per cent of the 
cases, if the examination is merely a routine one. A positive 
diagnosis is, therefore, impossible. The weight of the 
evidence, is, however, somewhat in favor of Encephalitis, 
sufficiently so to justify it as a provisional diagnosis. Time 
alone can decide whether or not it is correct. 

Prognosis. If the diagnosis of encephalitis is correct, 
the prognosis is very good. He will almost certainly recover 
entirely and be left without sequelae, either mental or 
physical. 

Treatment. The treatment can only be symptomatic. 
Nothing can be done in any way to modify the course of 
the encephalitis. 



548 CASE HISTORIES IN PEDIATRICS. 

CASE 171. Fred C, seven and one-half years old, had 
always been well except for measles and whooping-cough 
some years before. He had been spending the summer in a 
locality within twenty miles of which there had been several 
cases of infantile paralysis during the past few weeks. 

He complained of headache the afternoon of September 7. 
He vomited and was somewhat feverish the next morning, 
but went in bathing that noon as usual. He complained 
in the evening that his throat felt a little full. He was given 
a laxative that night and had a good movement the morning 
of the 9th. He was brought home that day by train, a 
journey of about one hundred and twenty-five miles. He 
took a little milk and ate several crackers on the way. He 
walked out of the station to his automobile without diffi- 
culty. He undressed himself and ate a little supper, although 
he complained that it was hard for him to swallow. He was 
seen by his physician in the early evening. The physical 
examination, including the throat, showing nothing abnormal. 
His mouth temperature was 103° F., his pulse 115, and rather 
feeble. He collapsed about midnight and was seen again 
soon after by his physician. He was then slightly cyanotic. 
His pulse was very feeble and his respiration rapid. He was 
unable to swallow anything, not even his saliva. He was 
given an enema of hot milk and brandy and soon rallied. 
His color continued bad and his respiration rapid, however, 
and he was unable to swallow. He was seen in consultation 
at 7.30 A.M., September 10. 

Physical Examination. He was well developed and 
nourished and perfectly clear mentally. His face and 
extremities were a little dusky. There was no rigidity of 
the neck. He could move his head, but could not turn 
himself in bed. The pupils were equal and reacted to light. 
There was no paralysis of the eye muscles and no facial 
paralysis. His respiration was rapid but not noisy. He 
was coughing constantly but feebly, and was all the time 
trying, but usually unsuccessfully, to spit up bloody, frothy 
mucus. He could stick out his tongue. There was no 
paralysis of the soft palate. The throat was normal to inspec- 
tion and palpation. He could speak a word or two at a time 



DISEASES OF THE NERVOUS SYSTEM. S4^ 

distinctly. Respiration was entirely diaphragmatic. There 
was no movement of the chest wall, and the accessory mus- 
cles of respiration were not acting. There was no retraction 
of the suprasternal, supraclavicular or intercostal spaces. 
The respiratory sound was feeble, alike on both sides and 
normal in character. No rales were heard in front; the 
backs were not examined. The cardiac area was normal, 
the action a little irregular, the rate 124, the first sound 
of fair strength, and there were no murmurs. The abdomen 
was normal. The liver and spleen were not palpable. He 
could move his arms, but the movements were feeble. The 
abdominal and cremasteric reflexes were present. The legs 
were not examined. 

Diagnosis. The normal condition of the throat, the clear 
voice, the quiet respiration and the absence of retraction 
rule out all forms of obstruction of the air passages. There 
is no disease of the lungs which causes bilateral immobility of 
the chest. Edema of the lungs from cardiac failure is sug- 
gested by the bloody, frothy expectoration, but is excluded 
by the normal size and fair strength of the heart and the 
absence of rales. The only possible explanation of the symp- 
toms is paralysis of the muscles of respiration. This explana- 
tion is justified by the physical examination. There is also 
a paresis of the muscles of the arms and trunk. The diffi- 
culty in deglutition and the irregularity of the pulse make 
it probable that the pneumogastric nerve is also involved. 
The only disease of the nervous system which will explain 
the sudden appearance of this combination of symptoms is 
acute poliomyelo-encephalitis, commonly known as Infan- 
tile Paralysis. 

Prognosis. The prognosis is absolutely hopeless. He will 
probably live but a few hours. 

Treatment. There is no treatment which can do more 
than perhaps delay the fatal outcome a few hours. Oxygen 
must be given freely. Strychnia and caffeln-sodlum ben- 
zoate or salicylate may be given subcutaneously. The 
administration of morphia subcutaneously is justifiable, 
if he is very uncomfortable. Even immune serum, granting 
that it may do good, would be useless at this time. 



55C CASE HISTORIES IN PEDIATRICS. 

CASE 172. John P., three years old, was the child of 
healthy parents and had always been well and strong. He 
had had a slight disturbance of the digestion August 20, 
which had yielded promptly to catharsis and regulation of 
the diet. He was restless and a little feverish during the 
evening of August 28, was given a large dose of castor oil by 
his mother and had several large, well-digested movements 
from it. It was discovered the next morning that he could 
not use his legs properly. He could move them in all direc- 
tions, but the movements were feeble. The rectal tempera- 
ture that morning was 101° F. There was no increase in the 
weakness of the legs during the day and he slept all that 
night. The loss of power was much more marked, however, 
the morning of the 30th. He complained of pain in his 
feet for the first time that morning. There was no disturb- 
ance of defecation or micturition. He had had no other 
symptoms. He was seen in consultation August 30 at 
10.30 A.M. 

Physical Examination. He was well developed and 
nourished and of good color. He was perfectly clear men- 
tally. There was no paralysis of any of the muscles controlled 
by the cranial nerves. The tongue was slightly coated; 
the throat was normal. The heart, lungs and abdomen 
were normal. The liver and spleen were not palpable. 
He used his arms freely. He held up his head well. He 
could sit alone, but rather feebly, the feebleness being due 
to the insufficiency of his legs. There was no deformity of 
the spine, which was normally flexible. The only motion 
which he could make with his legs was to flex the left toes a 
little. When the thighs were flexed on the body he could 
hold the left one there for an instant; the right dropped 
outward at once. The bones and joints were normal. 
Passive motions were not limited or painful. The abdominal 
and cremasteric reflexes were normal. The knee-jerks were 
absent on both sides. Kernig*s and Babinski*s signs were 
absent. Sensation to touch and pain was normal. There 
was no enlargement of the peripheral lymph nodes. The 
rectal temperature was 99° F. 

Diagnosis. The history and physical examination exclude 



DISEASES OF THE NERVOUS SYSTEM. 551 

at once, of course, injuries and diseases of the bones and 
joints. Rheumatism is not accompanied by flaccid paralysis. 
The paralysis must be due, therefore, to some disease of the 
nervous system. The absence of all symptoms of meningeal 
irritation, the clear mind, the paraplegic distribution of the 
paralysis and the absence of the knee-jerks exclude disease 
of the brain. The sudden onset and the absence of disturb- 
ances of sensation rule out disease of the peripheral nerves. 
The lesion must, therefore, be located in the spinal cord. 
The combination of loss of power and reflexes without dis- 
turbance of sensation occurs only in lesions of the anterior 
horns. Such lesions develop acutely in childhood only in the 
disease known as Infantile Paralysis. This is, therefore, 
the diagnosis. 

Prognosis. The chance of the extension of the process 
upward and of involvement of the respiratory muscles is so 
slight that a positively favorable prognosis as to life is allow- 
able. There will, in fact, in all probability be no further 
extension of the paralysis. The paralysis is certain to im- 
prove a great deal. It is impossible to state now how great 
the improvement will be. He may recover entirely, but will 
in all probability be left with considerable disability in the 
right leg and a little in the left. There will be little improve- 
ment after the first six months. 

Treatment. Nothing whatever can be done to modify the 
pathological process in the nervous system. There are no 
drugs which can possibly do any good, since the harm is 
already done. It is unreasonable to expect external applica- 
tions to have any effect on the spinal cord, which is located 
inside the vertebral column and has an entirely different blood 
supply from the superficial tissues. The only thing that they 
can do is to disturb the patient. There is nothing which 
can be done to shorten the course of the disease or to limit 
its progress, unless it be the intraspinal and intravenous in- 
jection of immune serum. This method of treatment is still 
sub judice. It is, at any rate, rather late to try it in this 
instance. 

There is no doubt that the use or the attempted use of the 
extremities involved tends, during the acute stage, to delay 



552 CASE HISTORIES IN PEDIATRICS. 

the process of repair in the nervous system and possibly, 
very early, to favor the extension of the process. He should, 
therefore, be kept as quiet as possible for six weeks, when the 
acute stage is presumably over. If he has much pain, he 
should be kept quiet for three weeks after the cessation of 
the pain. Massage and electricity have the same action as 
the use of the extremities and should not, therefore, be begun 
for six weeks. It is very important during this period, how- 
ever, to prevent the development of contractures, which make 
the subsequent treatment much more difficult. The weight 
of the bedclothes must be kept off of his legs by a cradle. 
A light wire splint will prevent extension of the feet and 
flexion of the knees. Strychnia is a stimulant to the motor 
nerves and is, therefore, contra-indicated during the acute 
stage. Hexamethylenamine cannot be expected to do any 
good, because it is only broken up in an acid medium. The 
body fluids and tissues are alkaline. It is, for the same 
reason, useless as a prophylactic remedy. It goes without 
saying, of course, that he must have good food and plenty of 
it, a liberal amount of fresh air and sunlight and good care 
in general. 

He should be isolated and the same precautions taken as 
in diphtheria and scarlet fever. Isolation should be con- 
tinued for three weeks. The other children should be kept 
out of school for two weeks after their last exposure. Adults 
should be allowed to continue at work, provided they do 
not see the patient or take proper precautions, if they do. 

After the expiration of the acute stage he can begin to try 
to use his legs, must have vigorous and active treatment by 
electricity and massage and will be helped by strychnia. 
Treatment is most effectual during the first six months. 
Little imxprovement can be expected after this time, except 
from muscle training. It is extremely important, therefore, 
to give him every attention during this time and not to put 
off treatment until some future period. 



DISEASES OF THE NERVOUS SYSTEM. 553 

CASE 173. Nathaniel F., nine years old, had not been 
away from home for some months and had seen no children 
except a few with whom he went to a private school near by. 
There had been but four cases of infantile paralysis in the 
whole state during the year and the last one of these was 
several months before. He had always been well, except 
for whooping-cough at four and measles at six years, although 
he had not been very vigorous until the past year. He was 
vaccinated November 2^. A number of other children who 
were vaccinated at the same time, by the same physician, 
with the same virus, were well. He did not seem quite like 
himself December 3 and 4, and lay around the house instead 
of going to school. His symptoms were attributed to the 
vaccination, although the wound was perfectly healthy and 
there was no undue inflammation about it. He seemed all 
right December 5 and 6, and the morning of December 7. 
He complained of headache on his return from school that 
noon, vomited and went to bed. He had a restless night and 
at times complained of severe headache. He was given 
calomel by his mother and his bowels moved freely in the 
morning. His legs seemed a little weak when he went to the 
bathroom the next morning. He was first seen by his 
physician at 10.30 A.M., December 8. His mouth tempera- 
ture was then 104.2° F., he was a little tremulous and at times 
irrational. The physical examination was negative. He 
grew rapidly worse during the day and became more and more 
irrational. When seen by his physician at 8.30 p.m. he com- 
plained of pain when his neck was moved, but took but little 
notice of anything else. The pupils were equal and reacted 
to light. The knee-jerks were equal, but diminished. The 
cremasteric and plantar reflexes were normal, but the ab- 
dominal were absent. He moved his arms well, but was able 
to move the legs only a little. The axillary temperature was 
103-5° F.; the pulse, 138; the respiration, 50. He continued 
to grow worse during the night and was seen again by his 
physician and a consultant at 2 a.m., December 9. He was 
then unconscious. The pupils were equal and reacted to 
light. He swallowed rather poorly. He was able to move 
his arms a little, but had no control over his legs, which were 



554 CASE HISTORIES IN PEDIATRICS. 

flaccid. The abdominal and cremasteric reflexes were absent, 
as were the knee-jerks. The left plantar reflex was normal, 
the right was much diminished. The bowels had moved 
involuntarily during the night and retention of the urine had 
developed. The urine was drawn by a catheter and found 
normal. Lumbar puncture showed no increase in the cere- 
brospinal pressure. The fluid was clear and no fibrin clot 
formed. No microscopic examination was made. The leu- 
cocyte count was 12,000. His temperature was kept down 
during the day by sponging. The pulse was regular and 
averaged about 130. The respiration continued rapid and 
became more and more diaphragmatic in type. He was 
unable to take nourishment and did not retain enemata of 
physiological salt solution. He was seen in consultation at 
midnight, December 9. 

Physical Examination. He was an exceptionally well 
developed and nourished boy. The cheeks were flushed. 
He was absolutely unconscious, except that when the eyelids 
were raised he looked around a very little as if he had a certain 
realization of what was going on about him. The pupils 
were equal and reacted to light. There was no strabismus. 
There was no rigidity of the neck or neck sign, and no spasm 
or paralysis of the facial muscles. The mouth and throat 
were evidently full of mucus, although they were not ex- 
amined. There was some drooling, but not as much as there 
would have been if he had not been able to swallow the 
greater part of his saliva. There was almost no motion of 
the right side of the chest and very little of the left, the 
breathing being mostly diaphragmatic. The heart and lungs 
were normal. The abdomen was level and negative. The 
liver and spleen were not palpable. There was complete 
flaccid paralysis of both the arms and legs. The abdominal 
and cremasteric reflexes were absent, as were the knee-jerks 
and the plantar reflexes. Kernig's sign was absent. It was 
impossible to determine whether or not he felt pain. The 
rectal temperature was 102.4° F.; the pulse, 128; the res- 
piration, 40. 

Diagnosis. The flaccidity of the paralysis and the absence 
of the superficial and deep reflexes show that the lesion is not 



DISEASES OF THE NERVOUS SYSTEM. 555 

located in the brain. The sudden onset, the high tempera- 
ture and the absence of pain and disturbances of sensation in 
the beginning are inconsistent with a peripheral paralysis. 
The lesion must, therefore, be located in the spinal cord. 
The combination of flaccidity and absent reflexes occurs only 
when the anterior horns are involved. The progressive 
character of the paralysis shows that the lesion is an ascending 
one. The only disease in which this combination of symp- 
toms occurs is the Ascending Type of Infantile Paralysis 
(Poliomyelo-encephalitis). The fact that it is December is 
not sufficient to exclude it, although infantile paralysis is rare 
in the cold months. It is noteworthy, however, that the 
weather had been unusually warm for the time of year for 
nearly two weeks. This suggests the possibility that some 
insect, usually destroyed by the cold, has acted as an inter- 
mediate host. 

Prognosis. The prognosis is practically hopeless. If the 
process stops where it is he will survive, but will be left more 
or less paralyzed. If it extends, as it almost certainly will, 
he will die of respiratory paralysis in the course of the next 
forty-eight hours. 

Treatment. The only method of treatment which can 
by any possibility have any action in limiting the extension 
of the pathological process is the injection of immune serum, 
both intraspinally and intravenously. This method of treat- 
ment is still sub judice. In this instance, on account of 
the wideness of the area involved and the rapid progress of 
the disease, little or no benefit can be expected from it. He 
should be given oxygen, if the difficulty with the respiration 
increases, and cardiac stimulants when they are needed. It 
will also be well to give him salt solution by rectum. It is 
hardly worth while to attempt to give him nourishment, 
however, until it becomes evident whether he is to survive 
or not, because he will not suffer from lack of food during 
the next forty-eight hours. 



556 CASE HISTORIES IN PEDIATRICS. 

CASE 174. Ambrose M., nine years old, had a sore throat 
the last week in March. He was not sick enough to be in bed 
and no physician was called. He returned to school after a 
week. His voice became somewhat unnatural about April 
25, and several days later liquids began to come through his 
nose when he drank. He found, May i, that he could not 
see the blackboard very well, and a few days later began to 
have some difiiculty in walking steadily. These symptoms 
were all present when he was seen, May 6. 

Physical Examination. He was well developed and nour- 
ished, but rather pale. His tongue was clean and was pro- 
truded in the median line. The gums were healthy. His 
throat was normal, except that the soft palate moved but 
little when he spoke. His voice was somewhat hoarse. 
There was moderate internal strabismus on the right. The 
pupils were equal and reacted to both light and accommoda- 
tion. The heart, lungs and abdomen were normal. The 
liver and spleen were not palpable. He moved his arms freely 
and his grip was strong. He moved his legs freely but with 
little muscular power. He walked a little unsteadily. His 
legs felt flabby and were rather cool. The knee-jerks were 
absent on both sides. The abdominal and cremasteric re- 
flexes were somewhat diminished. Kernig's and Babinski*s 
signs were absent. Sensation to touch was somewhat blunted, 
but that to pain and temperature was normal. There was 
no tenderness anywhere. There was no enlargement of the 
peripheral lymph nodes. 

The urine was normal in color, acid in reaction and of a 
specific gravity of 1,018. It contained neither albumin nor 
sugar. 

Diagnosis. The paresis of the legs in combination with the 
loss of the knee-jerks suggests to a certain extent infantile 
paralysis. A slow onset and a paraplegic distribution of the 
paralysis are, however, uncommon in infantile paralysis. 
The disturbance of sensation shows that the lesion is in the 
peripheral nerves, not in the anterior horns. The paresis of 
the soft palate and of the right external rectus is, moreover, 
not consistent with infantile paralysis, because, even with our 
present conception of the pathology of this disease, it would 



DISEASES OF THE NERVOUS SYSTEM. 557 

be hard to conceive of a poliomyelo-encephalitis resulting in 
paresis of the legs, one muscle of one eye and the soft palate 
and nothing else. The only possible explanation of this com- 
bination in a child of nine is a peripheral paralysis. 

This combination is almost pathognomonic of diphtheritic 
paralysis. The absence of pain and tenderness is also very 
characteristic. The history of a sore throat a few weeks 
before the onset of the paralysis makes the diagnosis of 
Diphtheritic Paralysis positive. The only other form 
of peripheral paralysis at all likely to occur in childhood, 
that due to lead poisoning, can be excluded, not only be- 
cause of the typical picture of diphtheritic paralysis which 
this boy presents, but also on the distribution of the paralysis 
and the absence of pain and tenderness and of a lead line 
on the gums. 

Prognosis. The prognosis is good. He will probably 
recover from the paresis of the eye and throat in six or eight 
weeks. The legs will probably not be well for from four to 
six months. The reflexes will not return until some time 
later. 

Treatment. He must not use his eyes for near work. 
It will be easier for him to take solid or semi-solid than 
liquid food. He must be kept reasonably quiet. Exercise, 
except in moderation, retards rather than hastens recovery. 
Care must be taken to prevent, by the use of passive motions 
or apparatus, the development of contractures. Massage 
and electricity must be begun at once. Faradism is prefer- 
able, if the muscles react to it; if they do not, galvanism 
must be used. It must be remembered in this connection 
that the object of both massage and electricity is merely to 
keep the muscles in good condition until the nerves resume 
their function, and that they have no direct curative action 
on the nerves. He should be given strychnia in doses of 
from one-sixtieth to one-thirtieth of a grain, three times 
daily, after eating. 



558 CASE HISTORIES IN PEDIATRICS. 

CASE 175. Alfred B., two years old, was the fourth child 
of healthy parents. There had been no deaths or miscar- 
riages. There was no tuberculosis in either family and there 
had been no known exposure to it. He was born at full term, 
after a normal labor, and was normal at birth. He was 
nursed during the first year; since then he had been on a 
general diet. He had never been sick. 

He was drowsy and somewhat feverish October 2, but had 
no other symptoms whatever, no headache, coryza, cough, 
vomiting or disturbance of the bowels. He seemed perfectly 
well the next day. His parents were sure that there was 
nothing the matter with him the morning of October 4. 
That afternoon, while running after his father in the yard, he 
tripped and fell down. When he got up it was noticed at 
once that his right arm was paralyzed. He did not cry at the 
time and did not seem hurt in any other way. He had been 
perfectly well since this time and had partially regained the 
use of his arm. He was seen October 23. 

Physical Examination. He was well developed and nour- 
ished and of good color. He was normal mentally. There 
was no rigidity of the neck or neck sign. The mouth and 
throat were normal. He had twelve teeth. There was no 
spasm or paralysis of any of the muscles supplied by the 
cranial nerves. There was no rosary. The heart and lungs 
were normal. The abdomen showed nothing abnormal. 
The lower border of the liver was just palpable in the nipple 
line. The spleen was not palpable. There was no spasm or 
paralysis of the left arm or legs. The knee-jerks were equal 
and normal. Kernig's sign was absent. The cremasteric 
reflexes were lively. The abdominal reflexes were not ob- 
tained. The right arm hung limp by the side. He was 
unable to raise it at the shoulder or to flex it at the elbow. 
Inward rotation of the humerus was normal, but he was 
unable to rotate it backward. Extension of the forearm on 
the arm was normal. He pronated the forearm normally, but 
could not supinate it as well as on the other side. All move- 
ments of the wrist and fingers were normal. There was visi- 
ble wasting of both the supra- and infra-spinatae and a little 
of the upper arm. The scapular muscles felt flabby, as did 
the deltoid and biceps. The sensation to touch was a little 



DISEASES OF THE NERVOUS SYSTEM. 559 

blunted over the area supplied by the right circumflex nerve. 
There was very little reaction to pain and no tenderness r.ny- 
where. The deep reflexes could not be obtained in either 
upper extremity. A Roentgenograph showed no evidence of 
injury about the right shoulder joint or of disease of the bones. 
There was no enlargement of the peripheral lymph nodes. 
The rectal temperature was normal. 

The urine was normal in color, clear, acid in reaction, and 
contained no albumin or sugar. 

Diagnosis. The persistence of the symptoms, the absence 
of pain and tenderness and the normal condition of the 
shoulder- joint and bones, as shown by the Roentgenograph, 
exclude injury to the shoulder- joint or disease of the bones 
as causes of the loss of power. The flaccidity of the paralysis 
rules out any cerebral lesion. The lesion must be located, 
therefore, in the lower motor neuron. The limitation of the 
paralysis to a portion of the muscles of one extremity excludes 
multiple neuritis. The sudden onset is inconsistent with a 
localized peripheral neuritis. The distribution is not like 
that of any of the usual types of this condition, and localized 
peripheral neuritis is extremely unusual at this age. The 
lesion must be situated, then, in the anterior horn of the 
spinal cord or in the nerve trunks. If it is situated in the 
anterior horn, the probable cause is acute poliomyelo-ence- 
phalitis (infantile paralysis). The history of malaise and 
fever two days before the onset of the paralysis strongly 
suggests this etiology. The sudden onset of the paralysis 
immediately after a fall is inconsistent with it. Is this story 
of the sudden onset of the paralysis true, or was the paralysis 
present before and not noticed until after the fall? If it was 
present before the fall the history is most characteristic of 
infantile paralysis; if it was not, the history is strongly 
against infantile paralysis and in favor of some injury to the 
nerve trunks. If this is the case, the malaise and fever two 
days before must have been due to some other cause and were 
purely a coincidence. It is impossible to know which is the 
truth. The father, who is a reasonably intelligent man, is 
positive, however, that the paralysis was not present until 
after the fall. Is there anything about the distribution of 
the paralysis which will aid in locating the lesion? The 



560 CASE HISTORIES IN PEDIATRICS. 

muscles involved are the supraspinatus and the infraspinatus, 
the deltoid, the flexors of the forearm, that is, the biceps and 
brachialis anticus, and, to a certain extent, the supinator 
longus. This distribution of the paralysis is exactly that 
which occurs in Erb's paralysis and obstetric paralysis, both 
of which are due to an injury to the brachial plexus. The 
ganglion cells of the nerves which supply these muscles are all 
located in the fourth, fifth and sixth cervical segments. The 
limitation of the lesion to these three segments is not incon- 
sistent with infantile paralysis. It would be most unusual, 
however, to have the lesion limited to the ganglion cells 
controlling just the muscles affected when the lesion is located 
in the brachial plexus, while the ganglion cells controlling 
other muscles are entirely unaffected. It seems much more 
reasonable that the lesion is located in the brachial plexus. 
Another point in favor of this location is the blunting of the 
sensation in the area supplied by the circumflex nerve (the 
motor nerve of the deltoid), which shows that the sensory as 
well as the motor fibres of this nerve are involved. This is 
more consistent with a lesion outside than within the spinal 
cord. The diagnosis of Erb's Paralysis, as the result of an 
injury to the brachial plexus at the time of the fall, seems, 
therefore, the most reasonable one. 

Prognosis. The prognosis must at present be somev/hat 
indefinite. There will undoubtedly be a great deal of im- 
provement in the paralysis. It is possible that there will be 
complete recovery, but, in all probability, some permanent 
disability will be left. How great this disability will be cannot 
be told for a year or two, after which time little improvement 
can be expected. 

Treatment. The arm must be placed in a sling to take the 
weight of the arm off of the shoulder muscles. He should be 
encouraged to use it, and passive motions should be made to 
prevent the development of contractures. Massage and 
electricity should be begun at once, the object of them both 
being to keep up the tone of the muscles until the nerves 
regain their power. Faradism should be used if the muscles 
react; if they do not, galvanism. There will be but little 
advantage in keeping up treatment after a year. 



DISEASES OF THE NERVOUS SYSTEM. 56I 

CASE 176. Joseph R., four years old, was the child of 
health}^ parents. Five other children were well and there 
had been no deaths or miscarriages. There had been no known 
exposure to tuberculosis. 

He was born at full term after a normal labor, was normal 
at birth and weighed ten pounds. He was nursed for ten 
months and did very well. He had otitis media, followed by 
mastoid inflammation and operation, when he was one and 
one-half years old, but made a perfect recovery. He had 
measles when three and one-half years old and mumps a 
few months later, but had otherwise been well and strong. 
He was said to have had pneumonia, lasting eight or nine 
days, in the early part of December, but was not very sick, 
and had no marked cerebral symptoms. Soon after getting 
up from the '' pneumonia " he began to stagger a little, '' as 
if drunk." The staggering increased rather rapidly in severity 
for a time and then remained unchanged. He also began to 
complain of occipital headache at about the same time. The 
headache was, however, never very severe, was not continu- 
ous and did not prevent him from sleeping. He began to 
vomit about Christmas and had continued to do so. The 
vomiting had no apparent relation to food. There were no 
other signs of indigestion, his appetite was good and his 
bowels moved regularly. He sometimes vomited with great 
force. He was bright and happy when his head did not ache, 
and played as much as his unsteady gait would permit. 
He had no trouble with sight or hearing and his memory was 
good. He was seen January 28. 

Physical Examination. He was fairly developed and nour- 
ished and of good color. His skin was rather dry. He was 
perfectly clear mentally. There was no tenderness on per- 
cussion of the skull. Mace wen *s sign was absent. There was 
no rigidity of the neck. He both saw and heard. The ear- 
drums were normal. The pupils were equal and reacted to 
light. The right eye showed an optic neuritis of the choked- 
disk type with a fair amount of swelling ; the left eye showed 
similar but less marked changes. There was no spasm or 
paralysis of any of the muscles controlled by the cranial 
nerves. He held his head up straight and sat up straight. 



562 CASE HISTORIES IN PEDIATRICS. 

His tongue was clean and the mouth and throat normal. The 
heart, lungs and abdomen were normal. The liver and spleen 
were not palpable. He used his hands normally. He walked 
a little unsteadily and, on turning, staggered and almost fell. 
There was no tendency to fall to one side more than to the 
other. There was no spasm of the legs, and when lying down 
he could make all motions without difficulty. The knee-jerks 
were equal and normal. Kernig's and Babinski's signs were 
absent. The cremasteric and abdominal reflexes were normal. 
Sensation to touch and pain was normal by rough tests. The 
genitals were normal. There was no eruption and there were 
no scars of old eruptions. There was no enlargement of the 
peripheral lymph nodes. The mouth temperature was 
98.6"^ F., the pulse 96, the respiration 24. 

The urine showed nothing abnormal. 

The white corpuscles numbered 8,000. 

A tuberculin skin test was negative. 

Diagnosis. The persistent vomiting without other symp- 
toms of indigestion, the projectile character of the vomiting, 
the occipital headache without disturbance of digestion, 
disease of the kidney or eyestrain, and the staggering gait 
without disease of the ears form a combination of symptoms 
that can be explained only by some trouble in the brain. 
The optic neuritis proves that there is a cerebral lesion. The 
condition is, of course, a chronic one. The first possibility 
which suggests itself is an abscess of the brain resulting from 
the otitis media two and one-half years before. Cerebral 
abscess is very rare at this age and a latent period of two and 
one-half years without any symptoms is most unusual. These 
facts, together with the normal condition of the ears and the 
absence of fever and leucocytosis, make an abscess extremely 
improbable. Another possibiHty is that the illness which was 
called pneumonia was, in spite of the lack of nervous symp- 
toms, an encephalitis and that the present symptoms are 
the result of it. It would be hardly possible, however, for an 
encephalitis to be mistaken for a pneumonia, although a 
pneumonia might easily be mistaken for an encephalitis. 
The lesions caused by an encephalitis would not be likely to 
cause an optic neuritis and would almost certainly produce 



DISEASES OF THE NERVOUS SYSTEM. 563 

some spasm, paralysis, change in the reflexes or mental dis- 
turbance. The most reasonable explanation for his symptoms 
is a rather rapidly growing cerebral tumor. The optic 
neuritis, projectile vomiting and staggering all point to it. 
The absence of Mace wen's sign does not count much against 
the presence of a tumor, because it is often hard to elicit and 
is often absent when the tumor is deep seated. The location 
of the pain in the occiput and the reeling gait make it probable 
that the Tumor is in the Cerebellum. The absence of spasm, 
paralysis and changes in the reflexes is negative evidence in 
favor of this location. Nearly fort}^ per cent of cerebral 
tumors in childhood are, moreover, in the cerebellum. 

It is impossible to more than guess at the nature of the 
tumor. The negative tuberculin test practically rules out a 
solitary tubercle, although about fifty per cent of the cerebral 
tumors in childhood are tubercular. Gumma is extremely 
rare at this age, the family history is good, there is nothing 
in his past history to suggest syphilis, and the physical exami- 
nation shows no sign of syphilis in the past or at present. A 
gumma can, therefore, be excluded. The chances lie between 
a glioma and a sarcoma, the former being somewhat the more 
probable as gliomata are more common than sarcomata at 
this age. 

Prognosis. The prognosis is hopeless. He will probably 
not live more than three or four months, perhaps not as long. 

Treatment. The treatment can be only symptomatic and 
for comfort. He must not be allowed to suffer pain when 
morphia will relieve him. It will be well, perhaps, to give him 
iodide of potash up to the physiological limit on the possi- 
bility that the tumor may be a gumma. It will probably do 
no good, but can do no harm. The chances of the successful 
removal of the tumor by an operation are practically nil. 
An operation for decompression would, however, probably 
relieve his symptoms temporarily. The facts should be 
stated to the parents and they should be allowed to decide 
as to whether or not they wish an operation. A lumbar 
puncture should not be done because it is very likely to cause 
sudden death when there is a cerebral tumor, especially if 
it is located in the cerebellum. 



564 CASE HISTORIES IN PEDIATRICS. 

CASE 177. Elizabeth C, three years old, was the only 
child of extremely neurotic but healthy parents. There had 
been no miscarriages. She had always been well. 

Her mother left her with an attendant one afternoon. 
She was pulled up from the floor by the arms a number of 
times and had also swung on a gate with her arms extended. 
She had had no fall. She complained a little of pain in her 
left arm before she went to bed, but nothing was thought of 
it. No one could tell whether she used her arm or not during 
the late afternoon before she went to bed. She slept well 
all night, seemed perfectly well in the morning and ate a 
good breakfast, but did not use her leit arm at all. She 
apparently had no pain in it. She was seen at 2 p.m. 

Physical Examination. She was well developed and nour- 
ished and of good color. She was very bright and much 
interested in her surroundings. There was no rigidity of 
the neck and no paralysis of any of the muscles controlled 
by the cranial nerves. She had twenty teeth. Her tongue 
was clean; her gums, mouth and throat were normal. There 
was a slight rosary. The heart and lungs were normal. 
The abdomen was rather large and lax, but otherwise normal. 
The liver and spleen were not palpable. Her left arm hung 
limply by her side with the palm turned backward and the 
fingers partially flexed. She would not reach out for or take 
hold of anything. There was no tenderness about the joints 
or bones or along the nerve trunks. There were no evidences 
of fracture or dislocation. There was no swelling or redness. 
Passive motions were not limited or painful. There was 
apparently no disturbance of the sensations to touch or 
pain. The reflexes of the arms were normal. She used her 
right arm and legs freely. The knee-jerks were equal and 
normal. Kernig's and Babinski's signs were absent. She 
was slightly knock-kneed, but there was no enlargement of 
the epiphyses at the wrists and ankles. There was no enlarge- 
ment of the peripheral lymph nodes. There were no mucous 
patches and no eruption or signs of old eruptions. The 
rectal temperature was 98.6° F. 

Diagnosis. Scurvy, while a possibility, is very improbable 
in a child of three on a general diet. It can be excluded on 



DISEASES OF THE NERVOUS SYSTEM. 565 

the localization of the symptoms in one extremity, the 
absence of pain on passive motion and the absence of swelling 
and tenderness. Syphilitic periosteitis can be ruled out on 
the good family and past history, the absence of signs of 
syphiHs in the past or present, the absence of local tenderness 
and swelling, and the localization in one extremity. Acute 
periosteitis or osteomyelitis can be excluded on the good 
general condition and the absence of fever, pain and tender- 
ness. The history of fleeting pain is like that of rheumatism 
at this age. Children do not stop using their extremities 
when they have rheumatism, however, and the pain is usually 
more general. The onset and development of the paralysis, 
although unusual, are not inconsistent with infantile paraly- 
sis, but the absence of fever and the retention of the reflexes 
practically exclude it. The position of the arm suggests 
that there may have been some pressure on the brachial 
plexus. It is hard to see how this could have happened in her 
case, and the absence of disturbances of sensation makes it 
very improbable. There is no dislocation or evidence of 
injury to the arm at present. It is very possible, however, 
that there may have been a partial dislocation of the shoulder 
as the result of the pulling up by the arms or of the swinging, 
with immediate spontaneous reduction. The subconscious 
memory of the pain caused by motion of the arm at that 
time may account for the failure to use it now. This seems, 
at any rate, the most plausible explanation. In an older 
child or adult it would be called an Hysterical Paralysis. 

Prognosis. The prognosis is perfectly good. If she can 
be sufficiently interested in some game or toy to forget 
herself entirely, she will use the arm at once. 

Treatment. The treatment consists in getting her mind 
entirely off of herself so that she will unconsciously use the 
arm again. 



566 CASE HISTORIES IN PEDIATRICS. 

CASE 178. Susan T., two and one-half years old, was 
brought to the Infants' Hospital from the Children's Aid 
Society, which had had her two weeks. Her forehead was 
large when she came to them and had not increased in size. 
Her mother had not noticed the enlargement but, when it was 
called to her attention, remembered that she had fallen out of 
bed some weeks before. She had had cerebrospinal menin- 
gitis six months previously, but had been well since then. 
While with the Children's Aid Society she had seemed per- 
fectly well, except that at times she acted as if her head was 
painful. 

Physical Examination. She was well developed and nour- 
ished and of fair color. She seemed normal mentally. The 
forehead projected forward, as is shown in the accompanying 
photograph. The swelling was symmetrical and hard, but 
not red or tender. The veins on its surface were enlarged. 
Pressure on it caused no discomfort, spasm of extremities or 
change in the pulse or respiration. There was no fluctuation. 
The fontanelles and sutures were closed. Percussion of the 
skull showed slight dullness in the left frontal region. The 
conjunctivae were not visible above the irides. There was no 
disturbance of vision and no spasm or paralysis of any of the 
muscles supplied by the cranial nerves. She moved her head 
freely, but rather guardedly. The heart, lungs and abdomen 
were normal. There was no rosary. The lower border of 
the liver was palpable two cm. below the costal border in the 
nipple line. The spleen and kidneys were not palpable. 
The extremities were normal. There was no spasm or 
paralysis. The knee-jerks were equal and normal. Kernig's 
and Babinski's signs were absent, as was the neck sign. She 
ran about and played without difficulty. The rectal tem- 
perature was 98.6° F. ; the pulse, 100; the respiration, 20. 

The leucocytes numbered 8,400. 

Diagnosis. The bulging of the forehead cannot be due to 
rickets, the enlargement in this disease being asymmetrical. 
There are, moreover, no other signs of rickets. The history 
of an attack of cerebrospinal meningitis some months before 
suggests hydrocephalus as the cause of the swelling. It 
would hardly be possible, however, for hydrocephalus to 




Susan T. Case 178. 



DISEASES OF THE NERVOUS SYSTEM. 567 

bulge out the forehead without causing separation of the 
sutures and general enlargement of the head. The fact that 
the conjunctivae are not visible above the irides shows, more- 
over, that there is no pressure downward on the orbital 
plates. There are no other signs of increased cerebral 
pressure, there being no spasm, paralysis or exaggeration of 
the deep reflexes. Pressure on the tumor causes no symptoms 
of cerebral irritation. Hydrocephalus can, therefore, be 
excluded. The history of a fall suggests some injury to the 
bones, with the formation of an abscess. The absence of 
redness, tenderness and fluctuation, the low white count and 
the normal temperature prove that this is not the case. The 
only other possibility is a new growth involving the frontal 
bones. The characteristics of the tumor are consistent with 
this diagnosis, as is the absence of all signs of increased 
cerebral pressure or irritation. New growths at this age are 
almost invariably sarcomatous. The diagnosis of Sarcoma 
OF THE Skull is, therefore, undoubtedly correct. Sar- 
comata of the skull at this age are almost never primary but 
secondary to sarcoma elsewhere, most often of the suprarenal 
capsule, but sometimes of the brain. There is no tumor in 
the kidney region in this instance, however, and there are no 
symptoms of increased cerebral pressure or of focal irritation, 
as would be expected if there were a tumor of the brain. 
These might be absent, nevertheless, if the tumor was small 
and situated in the frontal lobe. The dullness on percussion 
over the left frontal region is suggestive of the presence of 
such a tumor. It is, however, impossible to determine 
whether the tumor of the skull is primary or secondary to 
some focus elsewhere. 

Prognosis. The prognosis is practically hopeless. If the 
tumor of the skull is primary and can be removed, it is almost 
certain to recur, while if it is secondary, the original focus 
remains. 

Treatment. The only treatment which offers the least 
hope is the immediate ' removal of the tumor. 



568 CASE HISTORIES IN PEDIATRICS. 

CASE 179. James S. was the first child of healthy parents. 
There was no history of mental defect, insanity, paralysis or 
muscular dystrophy in either family. He was born at full 
term, after an easy labor, appeared normal at birth and 
weighed nine and three-quarters pounds. He was nursed 
entirely for five months, given milk and barley water in 
addition for five months and a rational diet during the last 
five months. He had never had any symptoms of indigestion 
and had had no illnesses, except a slight attack of bronchitis 
when a year old. He had always weighed more than the 
average baby of his age and had cut his teeth early, the first 
two having erupted when he was only five months old. He 
had developed normally mentally, but had always been back- 
ward about doing things. He did not hold up his head well 
until he was eight months old and then held it up very feebly. 
He still had some difificulty in controlling it long at a time. 
He could not sit up alone any length of time, but quickly fell 
over. His arms were weak at first, but he had used them 
well for a long time. He almost never attempted to use his 
le^s and was unable to roll over. He was brought on account 
of his backwardness, when fifteen months old. 

Physical Examination. He was a good-sized baby and of 
good color. The head was of good shape and of normal size. 
The anterior fontanelle was almost closed. He laughed, 
played and was undoubtedly perfectly normal mentally. He 
both saw and heard. The pupils were equal and reacted to 
light. All motions of the face were normal. There were 
eight teeth. The mouth and throat were normal. There 
was no disturbance of deglutition and his cry was loud and 
clear. He was able to hold up his head, but after a short 
time it fell limply to one side or the other. There was no 
rosary. The heart and lungs were normal and the respira- 
tory excursion was normal. He was unable to sit alone and 
when supported his back showed a marked curve of weakness. 
The spine was normal. The abdomen showed nothing ab- 
normal. The lower border of the liver was just palpable in 
the nipple line. The spleen was not palpable. There was 
no enlargement of the epiphyses at the wrists and ankles. 
He lay with the right thigh rotated outward. When the legs 



DISEASES OF THE NERVOUS SYSTEM. 569 

were straightened there was a moderate amount of knock- 
knees with separation of the legs. The heads of the femora 
were in normal position and passive motions at the hips were 
normal. He used his arms freely and they were reasonably 
strong, although the muscles felt somewhat flabby. He used 
his legs but little, but was able to make all motions with them, 
either wholly or in part, although feebly. The muscles were 
flabby, especially in the thighs. There was no apparent 
enlargement of any of the muscles of either the arms or legs. 
The knee-jerks, cremasteric and abdominal reflexes were 
absent, as was Kernig's sign. Sensation to touch and pain 
was normal. No urine could be expressed from the bladder 
and the anal sphincter was tight. There was no enlargement 
of the peripheral lymph nodes. 

Diagnosis. Weakness from malnutrition can be ruled out 
by the size of the baby, the good color and the absence of any 
disturbance of digestion or serious illness in the past. Mus- 
cular weakness from rickets can be excluded on the absence of 
all bony changes of this disease. Idiocy can be eliminated as 
the cause of the disturbance of motility because of the normal 
mental development. The absence of any acute illness in 
the past and the fact that the baby has never been normal 
rules out poliomyelo-encephalitis as the cause. The paresis 
resulting from this disease is, moreover, seldom so w^idespread 
as in this instance. It is almost never symmetrical and never 
involves all the muscles of an extremity to the same degree. 
There is no history of paralysis in either family, the weakness 
was noticed soon after birth, it involves all the muscles of the 
extremities to the same extent, there is no hypertrophy of any 
groups of muscles and the weakness is steadily diminishing. 
The muscular dystrophies, can, therefore, be excluded. The 
only disease left to be considered is amyotonia congenita. 
The history and physical examination of this patient corre- 
spond exactly to those of this condition. Amyotonia Con- 
genita is, therefore, the diagnosis. 

Prognosis. This condition has been recognized for so short 
a time that little is known as to the ultimate prognosis. The 
fact that but one case has been described in the adult makes 
it probable, however, that the children either die or recover 



570 CASE HISTORIES IN PEDIATRICS. 

completely. There is no involvement of the muscles of 
organic life in this instance, there has been a progressive 
improvement in the symptoms and the baby is normal in 
other respects. The outlook is, therefore, very favorable. 
He will probably be able to walk by the time he is three years 
old. It seems reasonable to expect that he will eventually 
attain full muscular power or that, if he does not, the weak- 
ness will not be sufficient to handicap him in any way. 

Treatment. There is no drug treatment which is of any 
use in this condition. He ought not to be forced to attempt 
to do things which he is unable to do. He should, however, 
be encouraged to do the things which he is able and given the 
best opportunity to exercise his muscles. This can be done 
by letting him play for a time once or twice daily in a warm 
room with his clothes off. Daily massage and the application 
of faradic electricity every other day will also aid in develop- 
ing the muscles. 



SECTION XIII. 

UNCLASSIFIED DISEASES. 

CASE 1 80. 1 Sadie H. was the first child of healthy parents. 
There had been no miscarriages. Her parents were Russians 
and not related. There was no history of idiocy or nervous 
diseases in either family. 

She was born at full term after a normal labor, and seemed 
normal at birth. She was nursed for ten months, after which 
she was given a general diet. Her appetite and digestion 
had always been good. Constipation began when she was 
two months old and had persisted. A dry and scaly condi- 
tion of the face, scalp and extremities developed when she 
was three months old and had resisted all forms of treatment. 
She had rather more hair than most children at birth, but 
this soon dropped out and no more appeared until she was 
nearly two years old. Her mother noticed when she was six 
months old that her tongue seemed too large for her mouth 
and that she drooled more than most babies. When she was 
eight months old her mother noticed that she was not as 
bright as other children of her age. Her mental development 
had, as time went on, dropped progressively farther behind 
that of other children of her own age. She was seen when 
three and one-fourth years old, and could then say only 
a few words. Her parents thought, however, that she 
understood much of what was said to her. She had not 
learned to control her sphincters. She cut her first tooth 
when she was two years old and began to sit up a little 
when she was two and one-fourth years old. She had not 
learned to creep or stand. Her large tongue made swallowing 
difficult and she drooled constantly. 

Physical Examination. She took considerable interest in 
her surroundings, but made no attempt to play with the 
toys offered to her, although she held them in her hands for 
a time. She knew her parents and said *' Papa " and 

571 



57^ CASE HISTORIES IN PEDIATRICS. 

*' Mamma " and a few other simple words. She was small 
but fairly nourished. Her skin had a peculiar yellowish 
pallor. She had considerable rather coarse hair. The face 
and the top of the head were covered with a dry, scaly erup- 
tion. The anterior fontanelle was closed. The head was of 
good shape, except that it was somewhat flattened on top. 
The bridge of the nose was flattened and the nostrils wide. 
The lower lids were rather full. She kept her mouth open and 
drooled constantly. The thickened and broadened tongue 
protruded just beyond the lips. She had six incisor teeth 
which, although only just through the gums, were much 
blackened. The throat was normal. Her voice was hoarse 
and deep. The rings of the trachea were distinctly pal- 
pable. The neck was not especially short, and there were no 
supraclavicular pads. She held up her head well but sat up 
rather feebly, with a marked general kyphosis. This was 
replaced by a slight lordosis in the lumbar region when she 
was held upright. There was a moderate rosary and a little 
flaring of the lower ribs. The heart and lungs were normal. 
The level of the abdomen was much above that of the thorax, 
but nothing else abnormal was detected in it. The lower 
border of the liver was palpable just below the costal border 
in the nipple line. The spleen was not palpable. The lower 
legs and feet appeared puffy but did not pit on pressure. 
The soles of the feet were flat, like those of an infant. The 
forearms and hands were also puffy, especially in the palms. 
The hands and feet were cold and the skin of the legs, feet, 
arms and hands dry, and in places scaly. There was no 
enlargement of the epiphyses, but the long bones of the 
extremities seemed larger in circumference than normal. 
The distance from the anterior superior spine to the sole of 
the foot was forty-four per cent of the body length, while 
it should be about fifty per cent. There was no spasm or 
paralysis. The knee-jerks were equal and diminished. 
Kernig's sign was absent. The external genitals were normal. 
There was a slight general enlargement of the peripheral 
lymph nodes. The rectal temperature was 98° F. She 
weighed twenty-two and one-half pounds (average is thirty- 
four and one-half pounds). 




Sporadic Cretinism. 



UNCLASSIFIED DISEASi:. ■>. 573 

Diagnosis. The history and physical examination of this 
child are so characteristic of Sporadic Cretinism that there 
is no opportunit / for a differential diagnosis. The com- 
bination of reta-ded mental and physical development, 
yellowish pallor, coarse hair, dry and scaly skin, thickening 
of the skin of the extremities, broad nose, large tongue, 
hoarse and deep voice, apparent absence of the thyroid 
gland, short legs, thickening of the long bones of the extremi- 
ties and subnormal temperature is pathognomonic of the 
disease. The flattening of the head, the rosary and the 
flaring of the lower ribs are undoubtedly signs of a compli- 
cating rickets. The dela^^ed dentition, the kyphosis and the 
enlargement of the abdomen may be due to either, but more 
probably to the cretinism. 

Prognosis. She will undoubtedly improve very materially, 
both mentally and physically, but too much must not be 
expected from the thyroid treatment when it is not begun 
until the patient is over three years old. The physical 
improvement will probably be much greater and more rapid 
than the mental. She will almost certainly, however, not 
attain normal stature, although her proportions will probably 
be approximately normal and she will be reasonably active. 
She will probably never develop sufficiently mentally to be 
a free agent or to support herself, although she will probably 
be able to do manual labor. 

Treatment. The treatment is with some preparation of 
the thyroid gland. The best preparation is the dessicated 
extract. The initial dose for this child is one half a grain, 
three times a day. It must be increased, one quarter of a 
grain at a time, until toxic symptoms appear. These are 
nervousness, fever and diarrhea. The dose must then be 
put back to the largest one which did not cause toxic symp- 
toms and kept there for many months. Later, it may be 
safe to give smaller doses. It is needless to say that she 
must continue to take thyroid extract as long as she lives. 
Her father's financial condition is poor. It will be wise, 
therefore, to place her in some institution for the care of 
the feeble-minded. 



574 CASE HISTORIES IN PEDIATRICS. 

CASE i8i. Rosamond S., the second child of healthy 
but neurotic parents, was born at full term, after a normal 
labor, was normal at birth and weighed seven pounds. She 
was nursed for eight months, after which she was given 
modified milk. This had been gradually strengthened, so 
that at the time she was seen she was taking whole milk and 
oatmeal jelly. She had never had any disturbance of diges- 
tion or illnesses of any sort. 

When she was six months old her mother noticed that her 
respiration was unusually rapid and that at times it was a 
little difficult. She was not sure, however, that these symp- 
toms had not been present previously. Her physicisn found 
nothing abnormal on physical examination at this time, but 
thought that the difficulty with respiration was chiefly expira- 
tory. The symptoms gradually increased in spite of the 
administration of the syrup of hydriodic acid for two months. 
The respiration continued rapid and was often a little wheezy, 
the wheeziness occurring both with inspiration and expira- 
tion. She was at times a little blue, but never markedly so. 
She never appeared uncomfortable, however, and apparently 
was not inconvenienced in any way. Slight suprasternal 
retraction had been noticed during the last month and dull- 
ness had been found under the manubrium. She was seen 
in consultation when one year old. 

Physical Examination. She was well developed and nour- 
ished, and of good color. She was bright and happy and 
seemed perfectly comfortable. The anterior fontanelle was 
one and one-half cm. in diameter and level. She had three 
teeth. She kept her mouth shut and there was no nasal 
discharge. The throat was normal to inspection and palpa- 
tion. Her cry and voice were clear. The respiration was 
rapid but regular. There was slight suprasternal retraction 
with inspiration. The relation between inspiration and 
expiration was normal. When she was quiet the respiration 
was inaudible; when she was active or excited it became a 
little wheezy. The wheezing was usually more marked in 
expiration than in inspiration. Extension of the head in- 
creased the wheeziness. An indefinite resistance was felt in 
the suprasternal notch, this resistance being more marked 



UNCLASSIFIED DISEASES. 575 

during expiration than during inspiration. There was moder- 
ate dullness under the upper portion of the manubrium, 
which did not extend down to the cardiac dullness or beyond 
the edges of the manubrium. The heart and lungs were 
normal. The intensity of the respiratory sound was the same 
on both sides. There was no dullness in the interscapular 
region and the respiratory and voice sounds were normal in 
character over the upper dorsal spines. There was no 
rosary. The abdomen showed nothing abnormal. The liver 
was just palpable in the nipple line. The spleen was not 
palpable. The extremities showed nothing abnormal. There 
was no spasm or paralysis. The knee-jerks were equal and 
normal. Kernig's sign was absent. There was no enlarge- 
ment of the peripheral lymph nodes. 

Diagnosis. The absence of nasal discharge and the closed 
mouth rule out adenoids and nasopharyngitis as the cause of 
the difficulty in respiration. The normal condition of the 
throat, both to inspection and palpation, rules out enlarge- 
ment of the tonsils and retropharyngeal abscess, while the 
clear voice and cry exclude disease of the larynx. The normal 
condition of the lungs rules out trouble below the trachea and 
primary bronchi. The absence of dullness in the inter- 
scapular region, the normal character of the respiratory and 
voice sounds over the upper dorsal spines, the equal intensity 
of the respiratory sound on the two sides and the increase in 
the dyspnea on extension of the head exclude enlargement of 
the tracheo-bronchial lymph nodes. The resistance in the 
suprasternal notch is strong evidence in favor of enlargement 
of the thymus. The increase in this resistance during expira- 
tion, in which phase of respiration the thymus is more easily 
palpable, makes this evidence stronger. The location of the 
dullness under the upper portion of the manubrium is char- 
acteristic of enlargement of the thymus. So also is the 
increase in the intensity of the symptoms on extension of the 
head, which narrows the upper opening of the thorax and 
hence increases the pressure exerted by an enlarged thymus 
on the neighboring structures. The diagnosis of an En- 
largement OF THE Thymus is, therefore, justified. A 
Roentgen ray photograph should be taken, however, to verify 



576 CASE HISTORIES IN PEDIATRICS. 

the diagnosis. The normal relation between inspiration and 
expiration is also of some importance in differentiating 
obstruction to respiration from enlargement of the thymus 
from that due to other causes. The greater intensity of the 
wheezing in expiration than in inspiration is rather unusual, 
but does not seem sufficient to invalidate the diagnosis. 

The enlargement of the thymus is almost certainly the 
result of simple hypertrophy. The good general condition, 
the slight amount of the enlargement after six months and 
the absence of enlargement of the lymph nodes rule out a 
malignant growth. There are no other signs of syphilis or 
tuberculosis and the general condition is better than would 
be expected if the enlargement was tubercular. The good 
general condition and the absence of fever exclude an abscess. 
All these affections of the thymus as well as cysts are, more- 
over, extremely rare, while simple hypertrophy is relatively 
common. 

Prognosis. The facts that the thymus is still compara- 
tively but little enlarged and that the symptoms of compres- 
sion have increased so little during the six months since their 
onset make it improbable that it will become large enough to 
cause any severe symptoms of compression before the normal 
atrophic changes, which begin at about two years, set in to 
cause retrogression in size. The slight degree of the enlarge- 
ment also makes it probable that the gland will diminish 
rapidly in size under treatment. It is possible, however, that 
the thymus may suddenly increase in size as the result of 
acute congestion and cause sudden death from compression. 
Enlargement of the thymus being in many instances a mani- 
festation of the condition known as ''status lymphaticus," 
it is also possible that she may die suddenly at any time. 
Both of these possibilities are, however, extremely improbable. 

Treatment. There is no drug treatment which will di- 
minish the size of the thymus. The symptoms in this 
instance are not severe enough at present to warrant thy- 
mectomy, which is a dangerous operation and which, if 
successful, is liable to be followed by interference with the 
normal development of the nervous and osseous systems. 
Treatment with the Roentgen ray is, however, safe and will, 



UNCLASSIFIED DISEASES. 577 

in all probability, hasten materially the involution of the 
enlargement. It should, therefore, be begun at once. As 
the symptoms are in no way urgent it will be wise, however, 
not to push the treatment, but to give short exposures at 
intervals of several days or even weeks. 



578 CASE HISTORIES IN PEDIATRICS. 

CASE 182. Sarah A., the second child of healthy parents, 
was born at full term, January 6, after a normal labor. She 
was cyanotic at birth and great difficulty was experienced in 
getting her to breathe. She had never breathed properly, 
but had not been cyanotic and had been able to nurse without 
difficulty up to the last ten days. Since then the respiration 
had been more difficult and she had had repeated attacks, 
lasting one-half hour or more, in which she breathed with 
great difficulty and became markedly cyanotic. The respira- 
tion was easier, both during and between the attacks, when 
she was held up than when she was lying down. She had had 
no other symptoms, had shown no evidences of indigestion 
and had gained steadily in weight as long as she was able to 
nurse easily. She was admitted to the Infants' Hospital, 
March 10, when nine weeks old. 

Physical Examination. She was fairly developed and 
nourished. Her color was good, except for a slight tinge of 
cyanosis about the mouth. The anterior fontanelle was 
three cm. in diameter and level. There was no nasal dis- 
charge and she kept her mouth shut. The throat showed 
nothing abnormal on either inspection or palpation. Her 
cry was clear and fairly loud. There was slight retraction in 
the suprasternal space and of the epigastrium with inspira- 
tion. This was more marked when she was lying down fiat 
than when she was reclining or bolstered up. Expiration was 
slightly prolonged, but the respiration was quiet. Extension 
of the head increased the difficulty in respiration. There was 
slight dullness under the manubrium, which was continuous 
with the cardiac dullness. Nothing abnormal was detected 
in the suprasternal space. The heart was normal. The 
respiratory murmur was somewhat feeble, but alike on both 
sides. The lungs showed nothing else abnormal. There was 
no dullness in the interscapular space and the cry was normal 
in character over the upper dorsal spines. The abdomen 
showed nothing abnormal. The lower border of the liver 
was palpable one cm. below the costal border in the nipple 
line. The spleen was not palpable. The extremities were 
normal. There was no spasm or paralysis. The knee- 
jerks were equal and normal. There was no enlargement of 



UNCLASSIFIED DISEASES. 579 

the peripheral lymph nodes. The rectal temperature wat 
99° F. 

During the attacks she became markedly cyanotic and 
breathed with great difficulty, even when sitting up. There 
was marked retraction of the suprasternal and supraclavicu- 
lar spaces as well as of the lower chest and epigastrium with 
inspiration. There was a whistling noise with both inspira- 
tion and expiration, more marked with expiration. Expira- 
tion was prolonged. The symptoms were much increased 
by extension of the head. 

Diagnosis. The absence of all physical signs of cardiac 
disease, the development of the attacks of cyanosis without 
evident cause and the signs of interference with the respira- 
tion rule out congenital heart disease as the cause of the 
symptoms. These must be due to some obstruction to the 
respiration, either within or without the respiratory tract. 
The absence of nasal discharge, the closed mouth and the 
paroxysmal exaggeration of the symptoms rule out adenoids 
and nasopharyngitis. Enlargement of the tonsils and retro- 
pharyngeal abscess are excluded by the physical examination. 
The clear cry shows that there is no trouble in the larynx. 
The greater intensity of the whistling noise in expiration, the 
prolongation of the expiration, the duration of the attacks 
and the persistence of the symptoms between the attacks 
rule out laryngismus stridulus. The normal condition of 
the lungs rules out trouble below the trachea and primary 
bronchi. The age of the baby, the absence of dullness in the 
interscapular region, the normal sound of the cry over the 
upper dorsal spines, the equal intensity of the respiratory 
sound on the two sides and the increase of symptoms on 
extension of the head and on lying down exclude enlargement 
of the tracheo-bronchial lymph nodes. Moreover, the symp- 
toms due to enlargement of these nodes rarely vary so 
markedly in severity as in this instance. The obstruction to 
the respiration must, therefore, be located in the trachea. 
The absence of catarrhal symptoms shows that the obstruc- 
tion must be due to pressure from the outside. The only 
organ in this region whose enlargement is likely to cause 
pressure on the trachea at this age is the thymus. The 



58o CASE HISTORIES IN PEDIATRICS. 

dullness under the manubrium is characteristic of enlarge- 
ment of the thymus. So also is the increase in the intensity 
of the symptoms on extension of the head and the variation in 
the severity of the symptoms without evident cause. Pro- 
longation of the expiration and greater difficulty in expiration 
than in inspiration are somewhat unusual when the obstruc- 
tion is due to Enlargement of the Thymus, but are not of 
sufficient importance to have much weight against the points 
in favor of this diagnosis. It should be verified, however, by 
a Roentgen ray photograph. Other causes of enlargement of 
the thymus at this age are so uncommon that it is safe to 
conclude that the enlargement in this instance is due to simple 
hypertrophy. The variations in the severity of the symptoms 
are in all probability the result of variations in the congestion 
of the organ. 

Prognosis. The outlook in this instance is most unfavor- 
able, because of the early development of the symptoms, the 
progressive increase in their severity and the occurrence of 
the suffocative attacks. She is likely to die suddenly in an 
attack or to gradually fail and die from malnutrition. Her 
only hope lies in the relief of the pressure by the removal or 
the reduction of the size of the thymus. 

Treatment. There is no drug treatment which will 
diminish the size of the thymus. Two lines of treatment are 
possible: operative, to relieve the pressure by the partial or 
complete extirpation of the gland, or by anchoring it in a new 
position; exposure to the Roentgen ray, to relieve pressure by 
causing its involution. The operative treatment is attended 
by considerable danger, but, if successful, the relief will be 
immediate. Treatment by the Roentgen ray is safe, but at 
best several days must elapse before any improvement can 
be expected and then the relief will be gradual. It is difficult 
to determine which method to adopt. Either course exposes 
the baby to grave dangers. It will probably be wiser, how- 
ever, to try first fairly long daily exposures to the Roentgen 
ray, and, if improvement does not begin in three or four days, 
to operate. 



UNCLASSIFIED DISEASES. 58 1 

CASE 183. Jacob Z. was the sixth child of healthy parents. 
The other children were well. There had been no mis- 
carriages. He was born at full term, after a normal labor, 
had been breast-fed and had been well except for occasional 
slight disturbances of digestion and "colds in t*he head." 

He developed a slight "cold in the head" and croupy 
cough February 15. A culture taken February 18 showed 
no Klebs-Loeffler bacilli, and the physical examination at 
that time showed nothing abnormal except a nasal discharge 
and moderate reddening of the throat. There was a dis- 
charge from the right ear, February 24, and on the twenty- 
eighth both ears were discharging freely. He had a convulsion 
on the twenty-eighth and another on the twenty-ninth. He 
took his food poorly after this, but did not vomit and had 
normal movements. The rectal temperature during the last 
week had ranged between 101° F. and 103° F.; his pulse, 
between 120 and 140; and his respiration, between 40 and 65. 
He was admitted to the Infants' Hospital, March i, when ten 
months old. 

Physical Examination. He was large and fat, but moder- 
ately pale. The anterior fontanelle was three cm. in diam- 
eter and level. There was slight rigidity of the neck, but no 
neck sign. He noticed, but did not take interest enough to 
reach out for things. The pupils were equal and reacted to 
light. There was a profuse purulent discharge from both 
ears. There was no swelling or tenderness over the mastoids. 
There was a profuse purulent nasal discharge, but the mouth 
was kept shut. The throat was generally reddened. The 
pharynx was slightly edematous on palpation. Digital 
examination of the larynx showed no swelling. The cry was 
clear. There was no dullness over the manubrium. The 
thymus could not be felt in the suprasternal space. There 
was no rosary. The heart and lungs showed nothing abnor- 
mal. The level of the abdomen was that of the thorax. 
Nothing abnormal was detected in it. The lower border of 
the liver was palpable four cm. below the costal border in the 
nipple line. The spleen was palpable three cm. below the 
costal border. The extremities showed nothing abnormal. 
There was no spasm or paralysis. The knee-jerks were equal 



582 CASE HISTORIES IN PEDIATRICS. 

and normal. Kernig's sign was absent. The cremasteric 
reflexes were feeble, the abdominal were not obtained. There 
was no enlargement of the peripheral lymph nodes. The 
respiration was regular, but very peculiar. Inspiration was 
sighing, while expiration was forcible and often accompanied 
by blowing out of the lips. There was no retraction any- 
where. He was slightly cyanotic unless kept by the open 
window. The rectal temperature was 103° F.; the pulse, 
124; the respiration, 50. 

The urine was normal in color, highly acid in reaction and 
contained a large trace of albumin, but no sugar, acetone or 
diacetic acid. The sediment showed a considerable number 
of hyaline and coarse granular casts* and casts with cells 
adherent, but no blood or blood elements. There was, 
however, no marked diminution in the amount of urine. 

The fluid obtained by lumbar puncture was under low 
pressure and perfectly clear. No fibrin clot was present after 
twenty-four hours. The fluid contained two cells per cubic 
millimetre. 

Diagnosis. The inflammation of the nasopharynx and 
middle ears is sufficient to account for the fever. It does not, 
however, explain the rapidity of the respiration or its peculiar 
type. If there was obstruction enough to the respiration in 
the nose and nasopharynx to increase the rate to this extent, 
the mouth would be kept open, the inspiration would not be 
sighing and the expiration would not be forcible. The 
absence of swelling at the entrance of the larynx and the clear 
cry rule out trouble in the larynx. The character of the 
respiration and the absence of retraction show, moreover, 
that the increase in the rate of the respiration cannot be due 
to obstruction either in the larynx or below it. The normal 
condition of the lungs rules out disease of these organs as the 
cause. This must be sought, therefore, outside of the respira- 
tory tract. The absence of all signs of meningeal irritation 
and the normal cerebrospinal fluid prove that it is not menin- 
gitis. It is conceivable that the rapid respiration may be due 
to reflex irritation from the ears. They are discharging freely, 
however, and otitis media rarely causes reflex symptoms after 
the discharge is well established. Reflex irritation would, 



UNCLASSIFIED DISEASES. 583 

moreover, not explain the cyanosis. The normal condition 
of the heart and the relatively slight increase in the rate of 
the pulse show that the rapid breathing is not due to cardiac 
failure. The changes in the urine are characteristic of acute 
degeneration of the kidneys and are not consistent with any 
of the conditions which cause uremia. This can, therefore, 
be excluded as the cause of the rapid respiration, as can also 
acid intoxication, since there are no acetone bodies in the 
urine. Sepsis is sometimes a cause of rapid respiration, but 
only when it is severe. The changes in the urine are un- 
doubtedly due to toxic absorption. The enlargement of the 
liver and spleen may be interpreted in the same way. The 
normal condition of the heart, however, makes this interpre- 
tation very improbable. There are, moreover, no marked 
general symptoms of sepsis, as would be expected if sepsis were 
the cause of the rapid breathing. The only condition which 
satisfactorily explains the peculiar, rapid respiration is status 
lymphaticus. Disturbances in respiration associated with 
cyanosis, not due to obstruction, are characteristic manifesta- 
tions of this disease. The occurrence of convulsions without 
definite cause is strong corroborative evidence of this expla- 
nation in this instance. The enlargement of the liver and 
spleen is consistent with this diagnosis. The absence of 
signs of enlargement of the thymus does not militate against 
it, because the symptoms in this condition are not due to 
the presence of an enlarged thymus but to some form of auto- 
intoxication. The diagnosis of Status Lymphaticus as the 
cause of the rapid and peculiar respiration is. therefore, a 
reasonable one. 

Prognosis. The prognosis is practically hopeless. He will 
almost certainly die during the next forty-eight hours. 

Treatment. There is no specific treatment for the status 
lymphaticus. He should be placed by an open window. 
He will probably breathe more easily if bolstered up than 
when lying down. There is no call for cardiac stimulants at 
present. They will, moreover, probably prove to be of little 
value. He should be nursed, if he will take the breast. If 
he will not, the breast-milk should be taken with a pump and 
fed to him in a bottle. If sufficient milk cannot be obtained 



584 CASE HISTORIES IN PEDIATRICS. 

in this way, he should be given modified milk in addition. A 
mixture containing 2% of fat, 6% of milk sugar, 1.50% of 
proteids and 0.75% of starch, without lime water, is a suitable 
one. He should be offered four ounces, eight times daily, at 
three hour intervals, but will probably not take it all. 

The ears should be syringed with warm water three or four 
times daily. It will probably be wiser not to disturb him 
by any active treatment of the nose. 



UNCLASSIFIED DISEASES. 585 

CASE 184. Rosamond M., eight and one-half years old, 
was the only child of healthy parents. There had been no 
deaths or miscarriages. She had had no known exposure to 
tuberculosis. She had always had a feeble digestion and had 
had to be fed very carefully. She had had chicken-pox and 
whooping-cough when seven years old and had had her 
adenoids removed when she was six years old. She had, 
however, continued to have frequent ''colds in her head." 
Her school and other duties prevented her from getting out of 
doors more than one, or at most two, hours a day. She had 
but little fresh air at night. 

She had an acute, but not very severe, attack of tonsillitis 
January 10, which was followed by enlargement of the cervical 
lymph nodes. They caused her no discomfort. Her appetite 
had been poor since then, but her digestion was not dis- 
turbed. She had no cough and, her mother thought, no fever. 
She was seen January 30. 

Physical Examination. She was fairly developed and 
nourished and of good color. There was no nasal discharge. 
She kept her mouth open most of the time, but could breathe 
freely with it shut. No adenoids were felt with the finger. 
Her tonsils were not enlarged and appeared healthy. Her 
throat was, however, very small and her palate highly arched. 
Her teeth were good and her tongue was clean. The heart, 
lungs and abdomen were normal. The liver and spleen were 
not palpable. The extremities were normal. There was no 
spasm or paralysis. The knee-jerks were equal and normal. 
There were numerous discrete, non-tender, freely moveable 
lymph nodes, varying in size from that of a pea to that of an 
almond, in both sides of the neck. The inguinal and axillary 
lymph nodes were not palpable. The bronchial voice was not 
heard below the seventh cervical spine, the air entered both 
sides of the chest alike and there were no evidences of in- 
creased pressure within the mediastinum. The mouth tem- 
perature was 98.4° F. 

The leucocytes numbered 8,400. 

Diagnosis. She has, of course. Cervical Adenitis. The 
absence of enlargement of the inguinal and axillary lymph 
nodes and of all signs of that of the tracheo-bronchial lymph 



586 CASE HISTORIES IN PEDIATRICS. 

nodes shows that it is a local process. There seems to be no 
reason to doubt the mother's statements that the enlargement 
was not present before the recent attack of tonsillitis and that 
it developed immediately after it. The process is, therefore, 
evidently an acute one. The most important point to be 
decided is whether it is simple or tubercular, leukemia being 
excluded by the low white count and pseudoleukemia being so 
improbable on account of its rarity that it need not be con- 
sidered at this time. There is nothing about the physical ex- 
amination which is of any aid in the diagnosis. When the 
cervical lymph nodes enlarge in the course of, or immediately 
after, some acute inflammatory condition in the nose or 
throat, they are almost never tubercular. When, on the other 
hand, they develop slowly, without obvious cause, they almost 
always are tubercular. The chances are, therefore, that the 
enlargement in this instance is non-tubercular. The absence 
of fever is slightly against tuberculosis, that of a leucocytosis 
in favor of it. Neither point is of much importance, how- 
ever, as simple adenitis often shows no leucocytosis after the 
most acute stage has passed and either condition may or may 
not be accompanied by fever. A single observation of the 
temperature, moreover, shows but little. The absence of a 
history of exposure to tuberculosis does not count at all 
against tuberculosis, because everyone is unknowingly ex- 
posed to tuberculosis so frequently. A positive diagnosis on 
the symptomatology^ and physical examination is, therefore, 
impossible. On the doctrine of chances, however, the en- 
largement is in all probability not tubercular. A skin 
tuberculin test should be tried. A negative reaction will 
practically prove that it is not tubercular. A positive reaction 
will prove nothing as to its character, because the reaction 
may just as well be due to some tubercular focus elsewhere 
as to the neck. If the tuberculin test is positive, a certain 
diagnosis can only be made after prolonged observation or 
by the examination of an excised node. 

The open mouth and the highly arched palate are the 
results of the adenoids in the past. 

Prognosis. If the enlargement is not tubercular, as it 
almost certainly is not, it will probably entirely or almost 



UNCLASSIFIED DISEASES. 587 

entirely disappear within a few weeks, although a few small 
nodes may persist. There is almost no chance of suppuration. 

Treatment. There are no external applications which will 
in any way hasten the resolution of these nodes. With the 
possible exception of iodine, there is no drug which, when 
given internally, will have any direct action upon them. 
The treatment consists in so regulating her life as to put her 
in the best possible general condition. It will be wise to 
send her to school but one session, so that she can spend more 
hours out of doors. She must have more air at night. There 
are no special indications as to her diet, which must be adapted 
to her rather feeble digestive powers. It will be well to give 
her eight drops of the tincture of nux vomica, in a table- 
spoonful of water, three times daily, before meals, to improve 
her appetite and as a general tonic. It will also be well, on 
account of the possible action of iodine in hastening resolu- 
tion, to give her twenty drops of the syrup of the iodide of 
iron, in water, three times daily, after meals. 

If the enlargement of the lymph nodes does not disappear 
in a few months the tonsils should be enucleated, in order to 
remove the original and possibly the continued source of 
infection and to diminish the chances of secondary infection 
with tuberculosis. 



588 CASE HISTORIES IN PEDIATRICS. 

CASE 185. Joseph O'C. was the second child of healthy 
parents. Two other children were well. There had been no 
deaths or miscarriages. There was no history of tuberculosis 
in either family and there had been no known exposure to it. 
He was born at full term, after a normal labor, and was normal 
at birth. His mother was unable to nurse him and great 
trouble was experienced in finding anything to agree with 
him during his first year. His digestion had been perfect since 
then. He had an attack of laryngeal diphtheria, requiring 
intubation, when he was twenty- two months old. This was 
followed, a month later, by bronchopneumonia, since when 
he had had repeated "colds " and several attacks of bronchitis. 
His rectal temperature had never been normal since the 
bronchopneumonia. It usually ranged between 100° F. and 
101° F., but was sometimes higher. He had been kept in bed 
most of the time during this period, because of the fever, not 
being up more than an hour a day. He had been out of doors 
during the summer, but had not been out at all during the 
winter. He had been carefully fed. His appetite and diges- 
tion were good and his bowels moved daily. He did not 
cough, except when he had a "cold." He had been taking 
a great variety of drugs. He was seen February 4, when 
three years old. 

Physical Examination. He was well developed and nour- 
ished, but a little flabby. His color was good. His tongue 
was clean and his teeth were in good condition. His throat 
was normal. No adenoids were felt with the finger. The ear- 
drums were normal. The voice was clear. There was no 
dullness under the manubrium. The heart, lungs and abdo- 
men were normal. The liver and spleen were not palpable. 
The extremities were normal. There was no spasm or 
paralysis. The knee-jerks were equal and normal. There 
were a few lymph nodes, about the size of peas, in both sides 
of the neck, but none were felt in the axillae or groins. The 
bronchial voice sound was audible over the upper five dorsal 
spines. There was no increased dullness or change in the res- 
piration in the interscapular space and the respiratory sounds 
were of the same intensity on both sides of the chest. The rectal 
temperature was 100° F.; the pulse, no; the respiration, 24. 



UNCLASSIFIED DISEASES. 589 

The urine was of normal color, clear, acid in reaction, of a 
specific gravity of 1015 and contained neither albumin nor 
sugar. 

The leucocytes numbered 8,000. 

Diagnosis. The physical examination shows that the con- 
tinued fever is not due to toxic absorption from the mouth, 
throat, nose or ears. The clean tongue, the good appetite, 
the absence of all symptoms of indigestion and the regular 
movements from the bowels show that it is not due to dis- 
turbance in the digestive tract. The normal urine excludes 
infection of the urinary tract and the absence of a leuco- 
cytosis shows that there is no hidden inflammatory process 
going on. The most probable explanation of the continued 
fever is, therefore, that there is a tubercular focus somewhere 
in the body. The fact that the fever followed an attack of 
bronchopneumonia points strongly to the chest as the seat 
of this focus. The lungs are normal. The bronchial voice 
sound over the five upper dorsal spines shows, however, that 
there is enlargement of the tracheobronchial lymph nodes. 
It is evident from the absence of dullness and bronchial 
respiration in the interscapular space and the equal intensity 
of the respiratory sound on the two sides, together with the 
absence of dullness under the manubrium and of all symptoms 
of pressure, that this enlargement is not very marked. It 
seems fair to conclude, therefore, that, in the absence of all 
signs of tuberculosis elsewhere, the cause of the fever is a 
tubercular Bronchial Adenitis. A Roentgenograph should 
be taken and a skin tuberculin test tried in order to confirm 
the diagnosis. 

Prognosis. The primary focus of tuberculosis at this age 
is almost always in the tracheobronchial lymph nodes. The 
tubercular process may extend from them directly to the 
lungs or the tubercle bacilli may be carried through the blood 
or lymph vessels, if they become infected, to any part of the 
body. In the vast majority of instances, however, the disease 
remains localized in the lymph nodes and recovery eventually 
takes place. It is impossible to know what will happen in 
this instance. He is in good general condition, there are no 
evidences of tuberculosis elsewhere, the enlargement of the 



590 CASE HISTORIES IN PEDIATRICS. 

tracheobronchial lymph nodes is slight and there is but little 
elevation of the temperature. The process is, therefore, not 
a very active one. The chances are, therefore, that there 
will be no extension and that he will eventually recover. 

Treatment. He must be kept out of doors as much as 
possible, preferably both day and night. If this is not 
feasible, the windows must be kept wide open when he is in 
the house. Too much attention has been attached to the 
elevation of temperature, which has been but very little 
above the normal limit for a three year old child. He should 
not be kept so closely in bed, but should be allowed to get up 
gradually and to take more exercise. This will improve his 
general condition and strengthen his resistance. His digestion 
being good, there is no reason for limiting his diet. All medi- 
cines should be stopped. 



UNCLASSIFIED DISEASES. 591 

CASE 1 86. George R., two and one-half years old, was 
the child of healthy parents. There were four other children 
living and well, none had died and there had been no mis- 
carriages. He had always been nervous but had had no 
illnesses. He had had nothing to eat the night before the 
onset of the present illness that had not been eaten by the 
rest of the family, but had been playing out in the snow that 
day and had got rather wet. 

He had a number of attacks of rather severe abdominal 
pain, lasting from fifteen minutes to an hour, during the night 
of January ii. He had no other symptoms and appeared all 
right the next day. Both ankles became painful and swollen 
January 13, and purpuric spots appeared on the ankles and 
lower legs the next day. That day he had a very severe 
attack of abdominal pain, followed by vomiting and diarrhea 
which lasted for about twelve hours. Neither the vomitus 
nor the stools contained blood. He was seen January 15 
by his physician, who found nothing abnormal on physical 
examination, except that both ankles were a little swollen 
and tender and had purpuric spots about them. The tempera- 
ture was then 99° F. and the pulse 140. He continued to have 
attacks of severe abdominal pain, lasting from one hour to 
two hours, but had no other symptoms of indigestion and the 
bowels moved normally. Both abdominal and rectal exami- 
nations were normal on January 18. The urine showed nothing 
abnormal. The temperature had varied between normal and 
99° F., the pulse between 120 and 150. 

He did well from that time to January 24, when his scrotum 
and penis suddenly became much swollen, the scrotum being 
nearly three times its usual size and very painful. The 
swelling was pinkish in color and did not pit on pressure. It 
lasted but a few hours. Purpuric spots appeared on the but- 
tocks at the same time. A similar swelling, the size of the 
palm of the hand, appeared over the sacrum the next day and 
disappeared again in a few hours. More purpuric spots also 
appeared on the buttocks. The attacks of abdominal pain re- 
curred on the 27th. Between them he apparently felt perfectly 
well. He had no fever. He had been kept on a light diet 
from the beginning, but this included eggs and broth. He 



592 CASE HISTORIES IN PEDIATRICS. 

was given citrate of potash at first and later three grains of 
the lactate of calcium daily. His bowels had been kept well 
open. He was seen in consultation January 28. 

Physical Examination. He was well developed and nour- 
ished and of good color. His tongue was slightly coated, his 
teeth in good condition. His gums and throat were normal. 
His heart and lungs were normal. The abdomen was a 
little sunken and showed nothing abnormal. There were no 
masses, no tenderness and no muscular spasm. The liver 
and spleen were not palpable. The penis and scrotum were 
normal. The extremities were normal. There was no spasm 
or paralysis. The knee-jerks were equal and normal. There 
was no Kernig's sign. There was no enlargement of the 
peripheral lymph nodes. There were a few fading purpuric 
spots about the ankles and buttocks. A rectal examination 
showed nothing abnormal. 

The urine was normal in color, clear, acid in reaction and 
of a specific gravity of 1,016. It contained neither albumin 
nor sugar. The centrifugalized sediment showed an excess of 
urates and an occasional small round cell, but no casts. 

Diagnosis. The attacks of abdominal pain with the at- 
tendant vomiting and diarrhea, the swelling and the purpuric 
eruption about the ankles, and the swelling and purpuric 
eruption about the genitals and buttocks are undoubtedly 
merely different manifestations of some abnormal systemic 
condition. The swellings which appeared in the genitals and 
over the sacrum have all the characteristics of angioneurotic 
edema. The eruption on the buttocks deserves the name of 
purpura simplex. The swelling and eruption about the ankles 
is typical of purpura rheumatica. The attacks of abdominal 
pain would be very hard to explain if they occurred alone, 
but associated, as they are, with other manifestations of 
purpura, they are quite characteristic of the condition known 
as abdominal purpura or Henoch's disease. Giving these 
various symptoms names does not, however, bring us much 
nearer the diagnosis of the underlying condition. It does 
emphasize the fact, however, that it is not justifiable to 
describe the different forms of Purpura as if they were dif- 
ferent diseases, and shows that they are merely different 



UNCLASSIFIED DISEASES. 593 

manifestations of the same condition. The association of 
the condition known as angioneurotic edema, which is pre- 
sumably due to a disturbance of the nervous control of the 
walls of the blood vessels, with the purpuric condition makes 
it probable that the purpura is due to some toxic action on 
the vessel walls rather than to a bacterial infection. This 
assumption is supported by the absence of fever. The 
presence of the angioneurotic edema in association with the 
purpura also makes it probable that the purpuric condition 
is not due to any disturbance of the coagulability of the blood. 
There is nothing in the history or physical examination to 
suggest the origin of the toxic substance. The normal con- 
dition of the gums and the good health of the other members 
of the family rule out lead poisoning. The good health of the 
rest of the family and the absence of symptoms of indigestion 
make intestinal toxemia very improbable. The etiology 
must, therefore, remain unsettled. It is possible that the 
eggs and broth may have had something to do with the con- 
tinuance of the condition, as they not infrequently cause 
angioneurotic edema. The attacks of abdominal pain may 
be due to an angioneurotic edema of the intestinal wall or to 
a hemorrhage into the wall. The short duration of the attacks 
and their frequent repetition, as well as the absence of blood 
in the stools, makes an edematous condition much more 
probable than a hemorrhagic. 

Prognosis. There is no danger as to life unless, as some- 
times happens, the local swelling in the intestinal wall 
causes an intussusception. The prognosis as to duration is, 
however, very indefinite as the condition not infrequently 
persists, with longer or shorter intermissions, for many weeks 
or even months. 

Treatment. The etiology being so obscure, the treatment 
can only be along general lines. He must be protected from 
chilling and overexertion. His diet should be limited to milk 
and starches, as they are less likely to form toxic substances 
in the intestines than are the fats and proteids. He must be 
given plenty of water and his bowels kept well open, preferably 
with salines. Although the calcium salts have no special 
influence on the coagulability of the blood, they have seemed 



594 CASE HISTORIES IN PEDIATRICS. 

clinically to be of some use in the treatment of angioneurotic 
edema and similar conditions. It will be well, therefore, to 
continue the lactate of calcium, but in larger doses, giving ten 
grains daily. Animal sera hardly seem indicated at present 
in this instance, because, if our reasoning is correct, the 
difficulty is not impaired coagulability of the blood. If the 
purpuric eruptions continue to recur, or if there are hemor- 
rhages elsewhere, it will be wise, nevertheless, to give them a 
trial. (See Case 17.) 

Heat externally and paregoric, in doses of fifteen or more 
drops, may be employed for the attacks of pain. 



UNCLASSIFIED DISEASES. 595 

CASE 187. William M. was the second child of healthy 
parents. The older child was living and well and there had 
been no deaths or miscarriages. He was born at full term, 
after a normal labor, was normal at birth and weighed five 
and one-half pounds. He was nursed for three months and 
then given equal parts of cows' milk and water. He did well 
on this until he was six months old. Since then he had 
vomited several times daily and had had from six to eight 
stools daily, some of which were green and some yellow. The 
stools had contained curds up to the last five weeks, during 
which he had taken nothing but barley water, prepared with 
a little salt. He had, nevertheless, gained two pounds during 
the last two weeks. He was admitted to the Children's 
Hospital when eight months old. 

Physical Examination. He was well developed and nour- 
ished. The skin and mucous membranes were of fair color. 
The anterior fontanelle was two cm. in diameter and level. 
The mouth and throat were normal. There were no teeth. 
Both the upper and lower eyelids were somewhat puffy. 
There was no rosary. The cardiac area and sounds were 
normal. There were no murmurs and there was no venous 
hum in the neck. The lungs were normal. The upper 
border of the liver flatness was at the upper border of the fifth 
rib in the nipple line ; the lower border was palpable three cm. 
below the costal border in the same line. The spleen was not 
palpable. The abdomen showed nothing abnormal. The 
feet were considerably and the legs moderately swollen. 
They were not red, hot or tender, but pitted on pressure. 
There was no enlargement of the peripheral lymph nodes. 
The rectal temperature was 98.6° F. He weighed fourteen 
and three-quarters pounds. 



Blood. 




Hemoglobin, 


55% 


Red corpuscles, 


4,764,000 


White corpuscles, 


13,000 


Small mononuclears, 


39% 


Large mononuclears, 


6% 



Polynuclear neutrophiles, 55% 



596 CASE HISTORIES IN PEDIATRICS. 

There was moderate achromia, but no irregularity in the 
size or shape of the red corpuscles and no polychromatophilia. 

The urine was clear, of normal color, acid in reaction, of a 
specific gravity of 1,012 and contained no albumin or sugar. 
The sediment, obtained by centrifugalization, contained a few 
leucocytes and small round cells. 

Diagnosis. He undoubtedly has a chronic disturbance of 
digestion. The most striking abnormality, however, and the 
one which requires explanation, is the edema of the face 
and lower extremities. It is fair to assume, also, that there 
is an accumulation of fluid in the tissues throughout the 
body, for it would manifestly be impossible for him to have 
gained two pounds in two weeks on barley water alone, ex- 
cept in this way. The normal condition of the heart and 
urine shows that the edema cannot be due to disease of the 
heart or kidneys. The blood shows a slight anemia, not 
sufficient, however, to account for the edema. It must be 
due in some way, therefore, to the digestive disturbance or 
to the food. It may be that the accumulation of liquid in 
the tissues is due to an excess of salt, and possibly of starch, 
in the food, which interferes with the normal processes of 
osmosis. It is conceivable that the walls of the blood vessels 
may have been directly injured as the result of the insufficient 
supply of food and of the absorption of toxic products from 
the intestines, and that they are consequently unduly perme- 
able. There is no proof, however, that this ever happens. 
It may be, on the other hand, that the increased permeability 
of the blood vessels is due to a disturbance of the sympa- 
thetic vaso-motor control, either from the disturbance of 
nutrition or from toxic or chemic irritiation of the terminal 
filaments of the nerves in the intestines or vessels. This 
possibility is also insusceptible of proof. It is wise, there- 
fore, with our present lack of knowledge, to continue to 
speak of this condition as Idiopathic or essential Edema, 
appreciating the fact, nevertheless, that it is really always 
a secondary manifestation of some other condition. 

Prognosis. His general condition is reasonably good, his 
heart and kidneys are normaji and there is but little anemia, 



UNCLASSIFIED DISEASES. 597 

in spite of the disturbance of digestion for two months and 
semi-starvation for five weeks. When these points are taken 
into consideration, it is evident that the edema, although often 
of serious import, is in this instance a relatively unimportant 
symptom and that it does not render the prognosis unfavor- 
able. He will undoubtedly recover promptly when he is given 
proper food. His weight will diminish rapidly until the 
excess of liquid in the tissues is eliminated, after which he 
should begin to gain again. 

Treatment. The treatment consists of regulation of the 
diet. The best food for him is, as in all disturbances of 
digestion in infancy, human milk. It is, however, not a 
necessity in this instance. He will undoubtedly recover 
without it. It will be wise to cut out the starch and salt in 
order to favor the elimination of the liquid in the tissues. It 
will also be well to keep the sugar a little low for the same 
reason. It will be advisable, on general principles, to give 
him a food relatively low in fat and relatively high in proteid. 
A whey mixture is contraindicated on account of the salts 
which it contains. A mixture which will fulfill these indica- 
tions is one containing 2% of fat, 5% of milk sugar and 2% 
of proteids, without lime water. Eight feedings of five ounces 
will be sufficient to cover his caloric needs, if the extra weight 
due to the edema is subtracted. He should not be given any 
extra water. There is no indication for medicinal treatment. 



598 CASE HISTORIES IN PEDIATRICS. 

CASE 1 88. Douglas S., nine years old, was the fifth child 
of healthy parents. The other children were living and well, 
none had died and there had been no miscarriages. There 
was no tuberculosis in either family and there had been no 
known exposure to it. He had always been well, except for 
measles when he was three years old. He was taken suddenly 
ill with infectious diarrhea, August i8, and had a very severe 
attack for his age. Improvement began about the tenth of 
September and was very rapid, the temperature coming down 
to normal and the movements to one in twenty-four hours, 
without mucus or blood. There was a recurrence of the fever 
and of the blood in the stools for a few days about the first 
of October. He improved again rapidly, however, and was 
sitting up in bed October 8 and 9. Since the beginning of his 
illness the diet had been almost entirely composed of carbo- 
hydrates. Two days later a little edema was noticed about 
the eyes and in the feet. This had increased, so that when he 
was seen, October 15, there was marked edema of the face and 
considerable edema of the feet, legs, posterior surface of the 
thighs and back. The temperature had been between 100"^ F. 
and 101.5° F., the pulse between no and 120 and the respira- 
tion between 25 and 30 since the appearance of the edema. 
He had taken his food well, but had had two or three loose 
movements from the bowels daily, which did not contain 
either mucus or blood. 

Physical Examination. He felt perfectly comfortable and 
his color was fair. The tongue was clean. There was no 
venous hum in the neck. The cardiac area was normal, the 
sounds were clear and strong, the action regular and there 
were no murmurs. There was moderate dullness, with slightly 
diminished respiration and voice sounds, in both backs below 
the angles of the scapulae. The lungs were otherwise normal. 
The liver and spleen were not palpable. The level of the 
abdomen was that of the thorax. There was shifting dullness 
in the flanks and a slight fluid wave. The extremities were 
normal except for the edema. There was no spasm, paraly- 
sis or disturbance of the reflexes. There was no enlargement 
of the peripheral lymph nodes. 

The urine was passed in sufficient amounts. It was pale, 



UNCLASSIFIED DISEASES. 599 

acid in reaction and of a specific gravity of 1,015. There was 
the sHghtest possible trace of albumin by the heat test, but 
none with nitric acid. It contained no sugar, acetone or 
diacetic acid. There was no sediment, even on centrifugal- 
ization. 

The blood contained 90% of hemoglobin and 3,636,000 red 
corpuscles. 

Diagnosis. The normal condition of the heart rules out 
disease or weakness of this organ as the cause of the dropsy. 
The anemia is so slight that it cannot be due to that. Al- 
though the urine contains the slightest possible trace of 
albumin by the heat test, it is passed in sufficient amounts 
and shows nothing else abnormal. The trace of albumin is 
in all probability due merely to a very slight degeneration of 
the kidneys from toxic absorption. It is well known that 
such slight degenerative changes do not interfere to any 
appreciable extent with the function of the kidneys. It is 
certain, at any rate, that there is no affection of the kidneys 
sufficient to cause a general dropsy. The dropsy must be 
due, therefore, in some way to the infectious diarrhea or to 
the food; that is, it belongs in the class of the so-called 
Idiopathic Dropsies, which are really always secondary and 
whose origin is extremely difficult to explain (see Case 187). 

Prognosis. His general condition is reasonably good, his 
heart is normal, there is but little anemia and the disturbance 
of his kidneys is trifling. There is no longer blood and mucus 
in the movements, which shows that in spite of the slight 
elevation of the temperature the inflammatory condition in 
the intestines is improving. It is reasonable to expect, 
therefore, that with improvement in the local condition in the 
intestines and the consequent improvement in the general 
condition the causes of the dropsy, whatever they may be, 
will become inactive and the excess of liquid will be quickly 
eliminated. 

Treatment. Table salt should be cut out of his diet and 
the intake of liquids limited. Twenty-four ounces of milk 
in twenty-four hours will be sufficient for him. He should 
have no extra water. The remainder of his diet should be 
made up of dry, starchy foods, such as toast, zweibach and 



600 



CASE HISTORIES IN PEDIATRICS. 



cracker. This diet not only diminishes the intake of liquid, 
but is also the one most suitable for his intestinal condition. 
There being no inflammation of the kidneys, it is safe to force 
them to eliminate more liquid by giving him five grains of 
theobromine-sodium salicylate, three times daily. If this 
does not increase the flow of urine, there will be no objection 
to giving him five minims of the tincture of digitalis, three 
times daily, increasing it to ten minims, three times daily, if 
necessary. (See Case 137.) 



UNCLASSIFIED DISEASES. 6oi 

CASE 189. Lincoln F., fifteen months old, was the second 
child of healthy parents. There had been no deaths or 
miscarriages. He was born at full term after a normal 
labor, was normal at birth and weighed ten pounds. He was 
nursed for seven months and then given modified cow's 
milk prepared at home, on which he did very well. Oatmeal 
water was added to his milk when he was eleven months old, 
but had to be stopped because it caused hives. He was then 
put on whole milk and mutton broth. Barley water had 
recently been added to the milk. He had lost his appetite 
during the last month, but had had no nausea or vomiting. 
He had been having from four to five small, green, foul 
movements, containing small curds and mucus, daily. He 
had been fussy and had had some colic. He had lost nearly 
two pounds in weight. 

Five days before he was seen all milk had been stopped 
and he had been put on beef juice, broth, white of egg and 
cereal jellies. He took his new food well and seemed better 
for three days, but had been very fussy the last two days, 
and had had five movements daily. These were loose, very 
dark in color and had a very foul odor. Swelling of the 
face appeared the day before, and that morning his hands and 
feet were also swollen. He was seen at 2 p.m. 

Physical Examination. He was well developed and nour- 
ished, but rather flabby. His color was fair. The anterior 
fontanelle was nearly closed. His face was somewhat puffy, 
especially about the eyes. It was not reddened, but evidently 
itched. He had three teeth. The gums, mouth and throat 
were normal, the tongue moderately coated. There was no 
venous hum in the neck. There was a slight rosary. The 
heart, lungs and abdomen were normal. The liver was 
palpable 2 cm. below the costal border in the nipple line. 
The spleen was not palpable. The extremities were normal, 
except that the hands and feet were somewhat swollen. 
The swelling was not hot or red and did not pit on pressure. 
There was no spasm or paralysis. The knee-jerks were not 
obtained. Kernig's sign was absent. There was a slight 
general enlargement of the peripheral lymph nodes. The 
rectal temperature was normal. 



602 CASE HISTORIES IN PEDIATRICS. 

The urine was high in color, turbid, very acid in reaction, 
of a specific gravity of 1,024, ^.nd contained no albumin or 
sugar. The sediment consisted of crystals of urate of 
ammonium. 

Blood. 
Hemoglobin, 65% 

Red corpuscles, 5,240,000 

White corpuscles, 12,000 

Diagnosis. He undoubtedly has a chronic indigestion and 
a slight amount of rickets. The condition which requires 
explanation is the swelling of the face, hands and feet. The 
analysis of the urine shows that it cannot be due to disease 
of the kidney, the heart is normal and, while the blood shows 
a very slight degree of anemia, it is not sufi&cient to cause 
edema, and there is no venous hum in the neck. The swell- 
ing does not pit on pressure, moreover, and itches, showing 
that it is not an ordinary edema. It must, therefore, belong 
in the class of the Angioneurotic Edemas. These are in 
all probability due to some disturbance of the vasomotor 
control of the blood vessels. In this instance the edema is 
almost certainly connected in some way with the digestive 
disturbance. It may be due either to irritation of the termi- 
nal sympathetic fibers in the walls of the intestines or to the 
absorption of toxic or chemical irritants from the intestines 
which act directly on the vascular terminal filaments of the 
sympathetic. It is, of course, impossible to say which. 
Its appearance at this time is probably connected with the 
change of food five days before, since no other element has 
been introduced. It cannot be due to the broth or jellies, 
because he has had broth and barley before without the ap- 
pearance of edema. It must be due, therefore, to either the 
beef juice or the white of egg. The excessively foul odor of 
the stools suggests decomposition of the beef juice and the 
production of toxic substances, while white of egg is known 
to be the food which most often causes angioneurotic edema. 

Prognosis. There is no danger connected with the an- 
gioneurotic edema. It is merely a side issue and does not 
alter the prognosis of the original indigestion. 



UNCLASSIFIED DISEASES. 603 

Treatment. The first thing to do is to stop both the beef 
juice and white of egg, either or both of which may be the 
cause of the swelling. The next thing to do is to give him 
two teaspoonfuls of castor oil to empty the intestines of the 
toxic products of the decomposition of the beef juice and 
egg, which they probably contain. It will be well to stop 
his food for twenty-four hours, giving him in its place at 
least one quart of water. Alkalies seem to hasten the disap- 
pearance of angioneurotic edema. He should, therefore, 
be given about a dram of the citrate or acetate of potash or 
of bicarbonate of soda, in water, during the twenty-four 
hours. Equal parts of skimmed milk and barley water will 
be a suitable mixture with which to begin, after the day of 
water diet. 



604 CASE HISTORIES IN PEDIATRICS. 

CASE 190. Robert C, four years old, was the child of 
healthy parents. He had always been well, except for 
occasional *' colds" and slight disturbances of the digestion. 
He was taken suddenly sick, during the evening of March 26, 
with fever, general malaise, headache and pains in the hands 
and wrists. It was noticed the next morning that his face 
was turned to the right and that there were large reddish, 
elevated areas on the backs of the hands and wrists. Similar, 
but smaller, spots appeared on the thighs and legs during the 
day. The fever and pain continued, but no new symptoms 
developed. His appetite was poor and the bowels consti- 
pated. He was seen at the Boston Dispensary in the morning 
of March 28. 

Physical Examination. He was well developed and nour- 
ished, but a little pale. The throat was normal, the tongue 
thickly coated but moist. The head was pulled down a little 
toward the left shoulder and the face turned to the right. All 
the motions of the neck were limited, but did not cause pain. 
The left sternocleidomastoid muscle was tense, but not tender. 
The heart, lungs and abdomen were normal. The liver and 
spleen were not palpable. There was no spasm or paralysis. 
The knee-jerks were equal and normal. On the dorsal 
surface of the hands and wrists were several dark-red areas, 
varying in size from that of a dime to that of a fifty-cent 
piece. These were not tender or painful, but were raised 
one-quarter of an inch or more above the surface and were 
surrounded by a zone of thickening. There were many 
smaller spots of the same character about the knees, both 
behind and in front. They also extended upward on to the 
thighs and downward on to the legs. There was no enlarge- 
ment of the peripheral lymph nodes. The mouth tempera- 
ture was 101° F. ; the pulse, 100; the respiration, 24. 

Diagnosis. The skin lesions are so characteristic of 
Erythema Multiforme that it is not necessary to consider 
any other conditions. The Torticollis, coming on as it did 
at the same time as the erythema, is undoubtedly also 
Rheumatic in origin. 

Prognosis. The prognosis as to life is, of course, good. 
The only danger is of the development of some cardiac com- 



UNCLASSIFIED DISEASES. 605 

plication. The torticollis will yield promptly to treatment 
with salicylic acid. The erythema may be more obstinate. 
It is possible, but not probable, that new crops may develop 
in spite of treatment. 

Treatment. He should be given five grains of aspirin every 
four hours until his temperature is normal and the pains have 
ceased, unless toxic symptoms develop. The dose should 
then be reduced to five grains, three times daily, in either 
case, and continued for several days longer. The neck does 
not require any local treatment. A simple dusting powder, 
such as one drachm of powdered zinc oxide to one ounce of 
starch, or stearate of zinc powder, will be all that is necessary 
for the skin. The bowels should be opened with some simple 
laxative, like licorice powder or syrup of senna, and his diet 
limited to milk, broths and starchy foods. He should be 
made to drink water freely and kept in bed until thoroughly 
convalescent. 



6o6 CASE HISTORIES IN PEDIATRICS, 

CASE 191. Anita F., six years old, had a mild attack of 
diphtheria, beginning February 10. Her temperature was 
never over 100° F., and the constitutional symptoms were 
slight. She was given 500 units of antitoxin February 11, 
3,000 February 14 and 3,000 February 16. Her throat was 
clear February 21, and a negative culture was obtained 
February 24. A profuse urticaria, accompanied by a slight 
rise of temperature, appeared February 26. She had a severe 
headache and very bad pains in the legs that night, so that 
she slept but little. The headache ceased on the twenty- 
seventh, but the pains in the legs continued with undiminished 
severity. They were less troublesome on the twenty-eighth, 
but motions of the legs caused much pain. The urticaria 
reappeared that afternoon. Her temperature had ranged be- 
tween 101.5° F. ^nd 102.5° F., while her pulse had been about 
120. She was seen in consultation at 6 p.m., February 28. 

Physical Examination. She was well developed and 
nourished. Her cheeks were flushed. Her tongue was 
moderately coated. Her throat was normal, except for slight 
redness of the fauces. The heart, lungs and abdomen were 
normal- The liver and spleen were not palpable. She lay 
with the thighs flexed on the body and the legs on the thighs. 
She was afraid to have her legs touched, but they could be 
slowly straightened without causing much pain. Motion at 
the ankles was free. There was slight swelling and tender- 
ness, but no redness, about the left knee, but none elsewhere. 
The knee-jerks could not be obtained because of the resist- 
ance. There was no enlargement of the peripheral lymph 
nodes. There were numerous erythematous areas, varying 
in size from that of a split pea to that of a silver dollar, 
scattered over the body and extremities. A factitious urti- 
caria was easily produced. The rectal temperature was 
103.3° F.; the pulse, 120; the respiration, 30. 

The urine was high in color, strongly acid in reaction and 
of a specific gravity of 1,028. It contained a large amount of 
urates, but no albumin or sugar. 

Diagnosis. The diagnosis of Antitoxin Poisoning, or 
serum sickness, is plain in this instance. The latter term, 
although not in common use in this country, is preferable to 



UNCLASSIFIED DISEASES. 607 

antitoxin poisoning, because the symptoms are not caused by 
the antitoxin but by the horse serum in which it is contained. 
Rheumatism, the only other disease which need be considered, 
can be excluded on the rash, the factitious urticaria and the 
history of the administration of antitoxin. Severe headache 
is, moreover, very unusual in rheumatism in childhood. The 
absence of swelling, redness and marked tenderness in the 
joints does not count against rheumatism, because these 
symptoms are comparatively uncommon in rheumatism at 
this age. 

Prognosis. There is no danger as to life or serious in- 
flammation of the joints. The pain and fever will probably 
persist for a number of days, or perhaps a week, longer. She 
will probably have a tendency to urticarial eruptions for 
several months. 

Treatment. There is no specific treatment for antitoxin 
poisoning. The salts of calcium, which were at one time 
thought to have such an action, are probably inert. The 
treatment must, therefore, be purely symptomatic. The diet 
should consist of milk and starchy foods. Eggs must be 
avoided because of their tendency to produce urticaria. 
Water should be forced. The application of heat externally 
and wrapping the legs in cotton will probably help the pains. 
If they do not, she may be given two and one-half grains each 
of phenacetin and salol every three or four hours. A mixture 
of equal parts of alcohol and water or a lotion made up of ten 
grams of powdered zinc oxide in one hundred cc. of a one- 
half of one per cent solution of carbolic acid may be used for 
the itching. If these applications do not relieve it, a saturated 
solution of camphor in ether may be painted on and allowed 
to dry. 



6o8 CASE HISTORIES IN PEDIATRICS. 

CASE 192. Evelyn S. was the only child of healthy 
parents. There had been no deaths or miscarriages. She 
was born at full term and was normal at birth. She had been 
very well taken care of and had never been sick. She was 
nursed for six months, after which she was given a mixture 
of whole milk and strained oatmeal until she was fourteen 
months old. Beef juice, broth, rice, eggs, toast, crackers, 
potato and baked apple had since then been gradually added 
to her diet. She had never taken more than two slices of 
bread and one potato daily, and had never been given sugar 
or sweets. She had been somewhat constipated for two 
months. Her mother thought that she had drunk rather 
more water and perhaps passed a little more urine during this 
time, but would have thought nothing of it if it had not been 
for the recent symptoms. Two weeks before she was seen 
in consultation, when twenty months old, she suddenly began 
to pass a great deal of urine and to be very thirsty. Her 
mother thought that she drank at least a quart of water daily. 
She was unable to tell how much urine she passed, but stated 
that she urinated every few minutes both day and night. 
The constipation had been more marked and she had lost 
weight and strength very rapidly. Her appetite and diges- 
tion had continued good and her diet had not been changed. 
She complained constantly of being tired and slept a con- 
siderable part of the time. 

Physical Examination. She was much emaciated and 
moderately pale. The skin of the face was dry, but it was 
not dry elsewhere. The tongue was somew^hat dry, but 
not coated. She had twelve teeth. There was no rosary. 
The heart and lungs were normal. The abdomen was 
sunken, but otherwise normal. The liver and spleen were 
not palpable. The extremities were normal. There was 
no spasm or paralysis. The knee-jerks were equal and 
normal. The cervical and inguinal lymph nodes were just 
palpable. 

The urine was pale, acid in reaction, of a specific gravity 
of 1,040, and contained the slightest possible trace of albumin. 
It contained a large amount of sugar, all of which was in the 
form of glucose. Both acetone and diacetic acid were present 



UNCLASSIFIED DISEASES. 609 

in considerable amounts. The sediment showed nothing 
abnormal. 

Diagnosis. The symptoms are characteristic enough of 
Diabetes IMellitus to justify this diagnosis, in spite of her 
tender age, without an examination of the urine. The find- 
ings in the urine confirm the diagnosis and also show that there 
is an acid intoxication. Alimentary glycosuria can be ex- 
cluded on the lack of an excess of carbohydrates in the food, 
the general symptoms of diabetes, the large amount of sugar 
in the urine and the evidences of acid intoxication. 

Prognosis. The prognosis is hopeless. She will probably 
not live more than a week, certainly not over a month. 

Treatment. The general principles of the treatment of 
diabetes are described in Case 193. It is very difficult to 
apply them and to regulate the diet in an infant of twenty 
months, whose food normally consists largely of milk, which 
contains a large amount of sugar, and starches. It is very 
hard to select a diet from the limited number of articles of 
food which are suitable for a baby of this age which will 
furnish a sufficient number of calories and not contain a large 
amount of carbohydrates. It is impossible to get along with- 
out both milk and starches. The amount of carbohydrates 
in the starchy foods cannot be diminished in any way. They 
must, therefore, be entirely excluded from the diet in the 
beginning. It is possible to use milk by taking advantage of 
the fact that cream contains a large amount of fat and a 
relatively small amount of sugar. If cream is diluted until 
the percentage of fat is no higher than the average infant 
is able to digest, the percentage of sugar is very low and the 
caloric value still reasonably high. A quart of whole milk, 
for example, contains 670 calories and 43 grams of sugar, 
while a quart of a dilution of one part of 32% cream with four 
parts of water contains about 600 calories and only 6.5 
grams of sugar. A healthy child of her age usually takes 
nearly 1,200 calories in twenty-four hours. She can un- 
doubtedly get along with 1,000 calories, or even less, for the 
present. One quart of a one to four dilution of 32% cream 
will give her 600 calories and 6.5 grams of sugar. The 
percentage of fat in this mixture, 6.4%, is rather high, but 



6lO CASE HISTORIES IN PEDIATRICS. 

probably not high enough to disturb her digestion. This 
must serve as the basis of her diet. She is old enough to 
digest eggs and beef juice. Two soft boiled eggs and two 
ounces of beef juice daily will add, respectively, 144 calories 
and 20 calories, making a total of 764 calories, without in- 
creasing the amount of carbohydrates. Broth is also allow- 
able, but has practically no nutritive value. If she is not 
reasonably satisfied with this amount of food, or continues 
to lose weight rapidly, it will be necessary to give her more, 
best in the form of diluted 32% cream, another pint of which 
will bring the caloric value of her food above 1,000. There 
is no other way in which the caloric value of her food can 
be increased as much with so little increase in the amount 
of carbohydrates, unless food which is certain to upset her 
digestion is given. 

The acetone and diacetic acid in the urine show that she has 
an acid intoxication. This should be combatted with bicar- 
bonate of soda. She can probably take as much as two 
drachms a day, perhaps even more. It can be best given in 
the milk. 



UNCLASSIFIED DISEASES. 6ll 

CASE 193. Charles W., eleven years old, was the child of 
healthy parents. One brother was living and well. There 
had been no deaths or miscarriages. His maternal grandfather 
had had diabetes, but had died of tuberculosis. 

He was born at full term, was normal at birth and weighed 
six pounds. He had whooping-cough when one year old, 
mumps and chicken-pox when small, and measles at four years, 
but had othenvise been well. He had always eaten much 
candy and had craved sweet foods. He had passed much 
more urine during the last month than formerly, and had 
drunk large quantities of water. He had to get up several 
times at night to urinate and to allay his thirst. His appetite 
was large. He had had no itching of the skin and no eruption. 
He was admitted to the Children's Hospital, August 3. 

Physical Examination. He was small and sparely 
nourished. He was moderately pale, but did not look or act 
sick. His skin was not dry or irritated, and there was no 
eruption. His tongue was slightly coated, the mouth and 
throat normal. The heart, lungs and abdomen were normal. 
The liver and spleen were not palpable. The extremities were 
normal. There was no spasm or paralysis. The knee-jerks 
were equal and lively. There was no disturbance of sensation. 
There was no enlargement of the peripheral lymph nodes. 
He weighed fifty-two pounds. 

He was allowed to eat as much as he wanted of the regular 
hospital diet, but was not allowed to put sugar on his food. 
He passed 560 ccm. of urine (the normal average is 1,200 
ccm.) August 4, of a specific gravity of 1,041, which con- 
tained 5.9% or 33.6 grams of sugar. It contained no albumin 
or acetone, and the sediment showed nothing abnormal. 

An accurate account of what he ate was then kept. He 
took 85 grams of carbohydrates August 6 and passed 855 ccm. 
of urine of a specific gravity of 1,018, which contained 1.8% 
or 15.3 grams of sugar, but no acetone. 

Diagnosis. There can be no doubt, of course, as to the 
diagnosis of Diabetes Mellitus. A simple glycosuria can 
be excluded on the persistence of the symptoms and the 
presence of sugar in the urine when there is only a moderate 
amount of carbohydrates in the food. 



6l2 CASE HISTORIES IN PEDIATRICS. 

Prognosis. There is practically no chance that he will 
recover, although, judging from the fact that he was able to 
make use of 70 grams of carbohydrates in twenty-four hours, 
the disease is not of a very severe type. His expectation 
of life is probably to be reckoned in months rather than in 
years, but he may, with careful treatment, live for a number 
of years. He is, however, very likely to suddenly develop 
acid intoxication at any time and die after a few days. 

Treatment. Drugs are of no use in the treatment of dia- 
betes. The treatment consists in regulation of the diet. 
The principles are simple. In the first place all food must 
be stopped until the urine is free from sugar. There is no 
danger, as was formerly supposed, of the development of 
acid intoxication as the result of starvation. If desired, he 
may be given one or two ounces of whiskey or brandy, 
in divided doses, well diluted with water, each twenty-four 
hours, or black coffee with saccharin. When the urine is 
free from sugar, he may be given limited amounts of those 
green vegetables which contain a very small amount of 
carbohydrates, such as lettuce, spinach, string beans, celery, 
asparagus, cucumber, cabbage and tomato. When these 
vegetables are cooked, the water should be changed twice 
while they are cooking. Vegetables cooked in this way 
have practically no nutritive value and act merely as " fillers." 
Many children prefer to go without food rather than to eat 
them. If this boy does not like them, it is not advisable 
to force him to take them. The caloric value of the food 
can then be increased by the addition of fats, and proteins. 
The proteins must be quickly increased until his mini- 
mum protein needs, approximately 45 grams, are covered. 
These must be met, as he cannot live or survive unless they 
are. If he cannot take enough protein to cover his mini- 
mum protein needs without the appearance of sugar in the 
urine, the outlook is hopeless and he will live but a short 
time. Carbohydrates should then be added to the diet 
until his tolerance is determined. In this instance, it was 
found that his tolerance for carbohydrate was about 60 grams 
daily. He should, therefore, be given between 50 and 55 
grams of carbohydrates daily, as it is important to give 



UNCLASSIFIED DISEASES. 613 

almost as much carbohydrate as he can utilize, in order 
to prevent the formation of the acetone bodies. The rest 
of his caloric needs must be furnished by fats and proteins. 
It must not be forgotten in this connection that sugar may 
be formed from proteins as well as from carbohydrates. 
His caloric needs are at least 1500 calories daily (see table, 
page 450). It is not a difficult matter to lay out a diet for 
him which will contain the proper number of calories and 
between 50 and 55 grams of carbohydrates, and also cover 
his protein needs, by the use of the table of food values given 
on page 449. For the more accurate calculation of the 
amount of carbohydrates in the various fruits and vegetables, 
the following abstract from the table compiled by Dr. E. P. 
Joslin (Treatment of Diabetes Mellitus. Lea & Febiger. 
1 916. Page 212) will be of use. 

CARBOHYDRATE CONTENT OF VEGETABLES AND FRUITS 

5% Lettuce, spinach and similar vegetables, celery, cabbage, cauliflower, Brussels 
sprouts, cucumbers, asparagus, tomatoes and egg plant. 
Grape Fruit. 
10 % Onions, squash, turnip, carrots and beets. 

Lemons, oranges, strawberries, melons and pineapples. 
15% Peas and parsnips. 

Apples, pears and most berries. 
20% Green com. 
Bananas. 

The available carbohydrate of the vegetables in the 5% 
and 10% group is only about 60% of the total carbohydrate. 
A reasonable diet for him for 24 hours is as follows: 











Grams 








Calories 


Fat 


Carbohydrate 


Protein 


Cereal 


2 ounces 


80 




17 


3 


Bread 


2 " 


150 




30 


6 


Meat 


4 " 


240 


12 




28 


Eggs 


4 " 


288 


20 




28 


Bacon 


2 slices 


180 


18 




3 


Butter 


2 ounces 


450 


48 






Olive Oil 


I ounce 


250 


28 






Spinach 


2 ounces 


8 




2 




String Beans 


2 " 


8 




2 





1654 126 51 68 

On this diet he should hold his weight and have no symp- 
toms. It will be advisable for him to have a starvation day 
once in two weeks. 



6l4 CASE HISTORIES IN PEDIATRICS. 

CASE 194. Byron H., thirteen and one-half years old, 
was the third child of healthy parents. His father denied 
syphilis and there had been no deaths or miscarriages. There 
was no history of any similar trouble in either family. He 
had always been well, except for whooping-cough as a baby 
and influenza when five years old. He had never had any 
injuries or symptoms of any disease of the nervous system. 
He was bright mentally, but rather excitable. He was very 
active, but did not get tired easily. About a month before 
he was seen, he began to pass water frequently during the 
day and had to get up at night to pass it. The increased 
frequency of micturition was not preceded by any unusual 
excitement, nervous shock or injury. The frequency of 
micturition gradually increased for two weeks, since when it 
had been about the same. Thirst began to be troublesome 
after the first week. He was passing between one and one- 
half and two gallons of urine in the twenty-four hours when 
he was seen, and was constantly drinking water. His appe- 
tite was normal, there was no disturbance of the digestion and 
he was not constipated. He had lost a little weight in the 
beginning, but had gained half a pound in the last week. He 
felt a little weary and had a slight headache during the first 
two weeks, but since then had been perfectly well. 

Physical Ezamination. He was tali and rather slight. His 
flesh was firm and his muscles were hard. His color was good, 
but his skin was somewhat dry. He was of a decidedly 
nervous temperament, but perfectly normal mentally. His 
pupils were equal and reacted to both light and accommoda- 
tion. All motions of the eyes were normal and there was no 
limitation of the field of vision. The fundi were normal. 
There was no spasm or paralysis of any of the muscles supplied 
by the cranial nerves. The tongue was clean and moist and 
the teeth were normal. The throat was normal. The area 
of cardiac dullness was normal, and the second sound at the 
aortic area was not accentuated. The radial arteries were 
not thickened and the tension of the pulse was not increased. 
The lungs and abdomen were normal. The liver and spleen 
were not palpable. The extremities were normal. There was 
no spasm or paralysis. The knee-jerks were equal and lively. 



UNCLASSIFIED DISEASES. 615 

Kemig's and Babinski's signs were absent. The sensation 
to touch, pain and temperature was roughly normal. There 
was no eruption on the skin and there were no scars of any 
old eruption. There were no mucous patches in the mouth 
or about the anus and no rhagades. There was no enlarge- 
ment of the peripheral lymph nodes. He weighed eighty and 
one-half pounds. 

He secreted six ounces of urine in the course of one-half 
hour while being examined, which was pale, slightly acid in 
reaction, of a specific gravity of 1,002, and contained no 
albumin or sugar. 

Diagnosis. The fact that the increase in the frequency 
of micturition preceded the thirst rules out polydipsia as the 
cause of the polyuria. The absence of remissions or inter- 
missions in the symptoms, of limitation of the field of vision 
and of disturbances of sensation excludes hysteria as the 
cause. The age of the child and the acute onset of the 
symptoms, together with the absence of albumin in the urine, 
enlargement of the heart, accentuation of the second aortic 
sound, thickening of the arteries and increase in the pulse 
tension, show that the polyuria is not a sign of chronic inter- 
stitial nephritis. There can be no doubt, therefore, that the 
trouble is Diabetes Insipidus. The absence of all signs of 
increased intracranial pressure and of involvement of the 
cranial nerves, as well as of an injury to the abdomen and of 
tumors in it, shows that it is of the primary or idiopathic 
type. Cerebral syphilis being the cause of a considerable 
proportion of the cases of diabetes insipidus, even when they 
are apparently primary, a Wassermann test should be done, 
in spite of the absence of a syphilitic history, of all signs of 
syphilis and of evidences of cerebral disease, to determine 
whether it is the etiological factor in this instance. 

Prognosis. The chances of recovery are very small, unless 
the condition is due to cerebral syphilis, in which case they 
are reasonably good. He will, however, probably live for 
many years and perhaps attain old age. 

Treatment. If the Wassermann test is positive, he should 
be treated for syphilis. If it is not, it is difficult to decide 
what drug, if any, to give him. The number of drugs which 



6l6 CASE HISTORIES IN PEDIATRICS. 

have been used and recommended in this disease shows of 
how little value they all are. Strychnia is perhaps more 
likely than the others to help him. He should be given one- 
sixtieth of a grain of the sulphate of strychnia three times 
daily, the dose being increased until it causes toxic symptoms. 
It should then be reduced a little below this point and given 
continuously for several months. If strychnia does not help 
him, ergot or valerian may be tried. It will be well to attempt 
to gradually reduce his intake of liquids. The reduction 
should be carried to the point where the amount of the urine 
ceases to diminish pro rata. Further reduction will be 
harmful, in that fluid will be drawn from the tissues to keep 
up the amount of urine. 

Although there are no evidences of a tumor at the base 
of the brain and no other symptoms pointing to disease of 
the pitaitary body, it is possible that there may be some 
lesion of this body or perhaps merely some disturbance of 
its function. There may be, as is apparently most common, 
an insufficiency of the posterior lobe. It may be worth 
while, therefore, to give him the extract of the posterior lobe 
or to feed it to him, either raw or cooked. 



UNCLASSIFIED DISEASES. 617 

CASE 195. Mary B. was the first child of healthy parents. 
There was no history of abnormal friability of the bones in 
either family. There had been no previous miscarriages. 
She was born at full term, after a normal labor lasting nine 
hours. The presentation was foot and leg. When the leg 
was pulled down, the mother being under ether, a snap was 
heard. She was delivered manually, but very little force was 
used. She was somewhat cyanotic and was held up by the legs 
to drain. When she was examined it was found that both legs 
were broken. She was seen in consultation five hours later. 

Physical Examination. She was well developed and nour- 
ished, of good color and seemed vigorous. The shape of the 
head was normal. The bones of the skull were hard and the 
fontanelles and sutures no wider than usual. The face was 
normal and there was no depression of the bridge of the nose. 
The shape of the chest was normal and there was no rosary. 
The heart, lungs and abdomen were normal. The liver was 
palpable two cm. below the costal border in the nipple line. 
The spleen was not palpable. The legs appeared shortened 
in their relation to the trunk, but the arms were of normal 
length and shape. There was no enlargement of the epiphy- 
ses of either the arms or legs. The right femur showed 
evidences of a healed fracture at about its middle. Union 
had occurred with an angular deformity outward and for- 
v/ard. There was but little callus and the fracture must have 
taken place at least three or four weeks before birth. There 
was a loose fracture with slight crepitus at the junction of the 
lower and middle thirds of the left femur. There was also 
a slight anterior bowing independent of the fracture. There 
was a fracture of the right tibia a short distance above the 
lower epiphysis, and two fractures of the left tibia, both at 
some distance from the epiphyses. The fibulae were intact. 
There was apparently some forward and outward bowing of 
the tibiae, which was not due to the fractures. The fractures 
were not markedly painful. There was no enlargement of 
the peripheral lymph nodes. The skin was soft, the hair fine 
and nothing abnormal was detected about the thymus and 
thyroid glands. 

Diagnosis. Cretinism and chondrodystrophia foetalis are 
suggested by the shortening of the legs. There are, however. 



6l8 CASE HISTORIES IN PEDIATRICS. 

no other evidences of cretinism and there is no increase in the 
friability of the bones in this disease. Chondrodystrophia 
can be excluded on the shape of the head, the normal length 
of the arms and the slightness of the shortening of the legs. 
Osteomalacia is a disease of later life. Fetal rickets, provided 
there is such a condition, can be ruled out on the normal con- 
dition of the skull and the absence of a rosary and of enlarge- 
ment of the epiphyses. Rachitic bones, moreover, are soft 
and bend but do not break or, if they do, the fractures are 
of the green-stick variety rather than complete as in this 
instance. The only condition with which the lesions in this 
baby are consistent is Osteogenesis Imperfecta, also known 
as idiopathic osteopsathyrosis and fragilitas ossium. This is 
undoubtedly the diagnosis. 

Prognosis. The prognosis as to life is grave, in spite of the 
good general condition, because the majority of the babies 
who are born with this disease die in early infancy. If she 
survives, she will undoubtedly continue to have repeated 
fractures from the most insignificant causes. The fragility 
of the bones gradually diminishes, however, and is much less 
marked after puberty than before it. The individual frac- 
tures heal quickly, and, if they are carefully treated, without 
deformity. 

Treatment. She must be kept on''a pillow and handled as 
little as possible. The clothes must be so arranged that they 
can be put on and taken off without disturbing the arms. 
She should not be put in a tub, but must be bathed on the 
pillow. She ought not to be put to the breast, but should be 
given breast-milk from a bottle. The fractures should, of 
course, be reduced and splinted in the usual way. There is 
no evidence to show that this disease is due to a deficiency of 
calcium. There is, therefore, no indication for its adminis- 
tration. Good results have been claimed from the use of 
phosphorus in this condition. It ought, therefore, to be given 
a trial. It is very likely to disturb the digestion, however, 
and on this account must be given very cautiously. It will 
be wise, therefore, to wait for some weeks before beginning it. 
The most reliable preparation is the phosphorated oil. The 
initial dose should be one-quarter of a minim, three times daily. 



UNCLASSIFIED DISEASES. 619 

CASE 196. Lena M. was the only child of healthy 
parents. There had been no miscarriages and the parents 
stated that they never had any venereal disease. She was 
born at full term, after a normal labor, and was normal at 
birth. She was fed on condensed milk during the first year 
and did well. She had had no disturbance of the digestion 
since then. In November, 1904, when a little more than 
three years old, she began to complain of pains in the axillae, 
for which no cause could be found. She had no pains else- 
where. She lost her appetite, became very thin and finally 
got so weak that she could not walk. She also had feverish 
spells every few days. This condition lasted until June, 
1905, when the pains and fever suddenly ceased and her 
appetite returned. She gained as rapidly as she had lost in 
the beginning and w^as soon perfectly well. She remained 
well until February, 1906, when she had the measles. This 
was followed by the suppuration of a gland in the neck, which, 
however, soon healed. About the middle of March the pains 
in the axillae returned and in a few days pains developed all 
over the body. She lost her appetite and again began to fail 
rapidly in flesh and strength. Swelling of the joints of the 
fingers appeared in two weeks. The wrists and knees next 
became swollen and finally the elbows and feet. The swelling 
of the joints varied from time to time, but never disappeared. 
Spontaneous pain ceased after a time, but pain on motion 
and handling persisted. She had seemed feverish at times, 
but, as a rule, there had apparently been no fever. There had 
been no disturbance of the digestion and her bowels had 
moved normally. Her appetite had improved during the 
last two weeks and she had regained a little weight. She 
was admitted to the Children's Hospital in August, 1906, 
when five years old. 

Physical Examination. She was poorly developed and 
emaciated. Her skin was brownish. There was no aural or 
nasal discharge. The tongue was clean, the teeth in good 
condition, the throat normal. She held her head rigidly in the 
median line and all motions of the head were much limited. 
She opened her mouth voluntarily only about one cm., but 
it could be forced open about twice as far. Roentgeno- 



620 CASE HISTORIES IN PEDIATRICS. 

graphs of the cervical spine, teeth and maxillary articula- 
tions showed nothing abnormal. The back was rigid and all 
motions were limited. The area of the cardiac dullness was 
normal, as was the action of the heart and the sounds, except 
for a soft, systolic murmur in the pulmonic area. The second 
pulmonic sound was not accentuated and there was a venous 
hum in the neck. The lungs and abdomen were norm.al. 
The liver was palpable one cm. below the costal border in the 
nipple line. The spleen was just palpable. There were 
fusiform swellings, which were slightly reddened and tender 
to pressure, about the elbows, knees, carpal, metacarpocarpal 
and metatarsotarsal joints, all the phalangeal joints of the 
hands, except the second joints of the two middle fingers and 
the distal joints of the thumbs, and the maxillary. The 
movements of all these joints wxre limited and painful. 
Roentgenographs of the hands showed enlargement of the 
distal portions of the two proximal phalanges, except of those 
not clinically affected, which was due to a proliferation of the 
periosteum, and slight blurring of the epiphyseal centres of 
the affected portions. The legs w^re held flexed at a right 
angle on the thighs. There was no limitation of motion at 
the hip and shoulder joints. There was much wasting of the 
muscles of both the arms and the legs. The knee-jerks were 
present, but diminished. There was no disturbance of the 
sensation to touch and pain. There was a general enlargement 
of the peripheral lymph nodes, including the epitrochlear and 
occipital, which varied in size from peas to almonds. There 
were no rhagades or mucous patches and no eruption or 
scars of former eruptions. The rectal temperature was 99° F. ; 
the pulse, 120. 

The urine was normal in color, acid in reaction, of a specific 
gravity of i ,023 and contained no albumin, sugar or acetone. 

Blood. 

Hemoglobin, 50% 

Red corpuscles, 3,700,000 

White corpuscles, 13,000 

Mononuclears, 20% 

Polynuclear neutrophiles, 79% 

Mast cells, 1% 




Lena M. Case 196. 



UNCLASSIFIED DISEASES. 621 

Diagnosis. The appearance of the swellings In the joints 
after measles and an abscess of the neck, the number of the 
joints Involved, the fusiform character of the swellings, the 
enlargement of the spleen and peripheral lymph nodes, 
the anemia, the discoloration of the skin and the relative 
increase In the rate of the pulse in comparison with that of the 
temperature are all so characteristic of that form of infectious 
arthritis known as Still's Disease that there is no oppor- 
tunity for a differential diagnosis from other forms of arthritis. 
The absence of changes in the bones and cartilages of the 
affected joints, as shown by the Roentgenographs, confirms 
this diagnosis. The systolic murmur at the pulmonic area 
and the venous hum in the neck are merely signs of the 
anemia, while the slight enlargement of the liver is probably 
due to fatty change resulting from the disturbance of the 
nutrition. 

Prognosis. There is no danger as to life. The process is 
likely to continue for many months or even for a number of 
years, however, perhaps skipping from joint to joint. She. 
will then recover her health and the swellings will in a great 
measure disappear, but she will probably be left with more or 
less deformities as the result of adhesions and thickening 
about the joints. 

Treatment. The salicylates and iodides are useless in this 
disease. In this Instance there are no symptoms which point 
to the digestive tract as the source of the toxemia. There 
are, therefore, no definite indications as to what she should 
or should not eat. She ought, therefore, to be given a liberal, 
easily digestible diet. Meats and foods prepared from them 
are not contralndlcated. It is very possible that there is a 
mild bacterial infection at the bottom of the trouble. Un- 
fortunately, experience has shown that blood cultures are 
almost invariably negative and the liquid aspirated from the 
joints sterile in this disease. It being, therefore, Impossible 
to determine the organism, and as only an autogenous vac- 
cine can be expected to do good, it hardly seems rational 
to give stock vaccines of many organisms on the chances 
that one of them may be the right one. She should 
be given iron for the anemia. The saccharated oxide is a 



622 CASE HISTORIES IN PEDIATRICS. 

good preparation. Five grains, three times daily, should be 
sufficient for her. She should be put on a frame with 
traction on the legs and the affected joints baked daily. 
The further treatment should be directed by an orthopedic 
surgeon. 



UNCLASSIFIED DISEASES. 623 

CASE 197. Paul K., nine months old, was the second 
child of healthy parents. There had been no deaths or mis- 
carriages and no known exposure to tuberculosis. He was 
born at full term, after a normal labor, and was normal at 
birth. He was not nursed and some difficulty was experienced 
in feeding him up to the time he was three months old, since 
when he had thrived in every way. He began to be sick 
about August i. He was fussy and evidently in pain. He 
vomited a little at first, but this stopped when his food was 
weakened. He had had no disturbance of the bowels. His 
mother noticed August 16 that he "favored" his left leg a 
little. He was first seen by his physician, August 19. He 
found a temperature of 100° F., but nothing abnormal on 
physical examination. The temperature had ranged be- 
tween 99° F. and 101° F. since then. He was very fussy and 
it was evident that he was in pain. The physician was, how- 
ever, unable to locate its seat. He slept much better than 
usual the night of August 22, and the next morning his mother 
found that his left thigh was much swollen. Both she and 
the physician were sure that it was not swollen the day before. 
In spite of the swelling, he seemed more comfortable than for 
several days. He was seen in consultation at 4 P.M., August 23. 

Physical Examination. He was pale and feeble and had 
evidently lost much weight. He was evidently in consider- 
able pain. The anterior fontanelle was four cm. in diameter 
and depressed. The pupils were equal and reacted to light. 
There was no rigidity of the neck or neck sign. The ear- 
drums were normal. He had two teeth. The mouth, gums 
and throat were normal. There was no rosary. The heart, 
lungs and abdomen were normal. The spine was flexible. 
The lower border of the liver was palpable two cm. below 
the costal border in the nipple line. The spleen was not 
palpable. The arms and right leg were normal. He lay 
with the left thigh flexed on the body and rotated outward 
and the leg flexed on the thigh. The left thigh was much 
and somewhat irregularly swollen. The swelling was most 
marked in the upper portion and did not extend on to the 
abdomen or leg. It was not in the superficial tissues and did 
not pit on pressure. It was moderately tender, but not red 
or hot. The whole left lower extremity was mottled, but the 



624 CASE HISTORIES IN PEDIATRICS. 

pulse was palpable in the foot. All motions at the left hip 
were much limited and painful, those at the knee were free. 
The right knee-jerk was normal and Kernig's sign was ab- 
sent on that side. They could not be determined on the 
left, because of the rigidity. There was no enlargement of 
the peripheral lymph nodes. The rectal temperature was 
100.4° F-J the pulse, 160; the respiration, 32. 

The urine was of normal color, clear, acid in reaction and 
contained no albumin. 

Diagnosis. Rheumatism can be excluded on the age of the 
baby and the location of the swelling. Scurvy can be ex- 
cluded on the localization of the swelling over one bone, the 
sudden appearance of the swelling, the absence of tenderness 
elsewhere and the normal condition of the gums. The long 
continuance of pain and fever without any local manifesta- 
tions, except a little unwillingness to use the left leg, and the 
sudden appearance of the swelling with the simultaneous 
diminution in the pain, is almost pathognomonic of the 
rupture of a collection of pus which has been slowly accumu- 
lating. The location of the swelling shows that the abscess 
was located somewhere in the neighborhood of the hip joint. 
It was in all probability in the joint itself and, judging from 
the size of the swelling, also in the pelvis. When the capsular 
ligament ruptured, the pus escaped into the neighboring 
tissues. The diagnosis of Acute Arthritis of Infants is, 
therefore, justified. The acute arthritides at this age are very 
seldom tubercular. They are in most instances due to an 
infection of the bone, usually in the neighborhood of the 
epiphyseal line, with one of the pyogenic organisms, the 
joints being involved secondarily. This is probably the case 
in this instance. 

Prognosis. The condition is a very serious one. He is 
in reasonably good shape, however, and there are no evidences 
of general sepsis or of the involvement of other bones or 
joints. There is a reasonable chance of his recovery, there- 
fore, provided he is operated on at once. If he survives, he 
will almost certainly have a useful joint. 

Treatment. The abscess cavity must be opened, cleaned 
out and drained. 



UNCLASSIFIED DISEASES. 625 

CASE 198. Penelope C, eleven months old, had had much 
trouble with her digestion until she was six months old, when 
a wet-nurse was procured for her. She had done uninter- 
ruptedly well since then and w^as still on the breast. She had 
cut three teeth without any marked discomfort or disturbance 
of any sort. She began to be fussy and to put her hands in 
her mouth, September 3. She fussed, cried out and kept put- 
ting her hands in her mouth all through the night of Septem- 
ber 6. Her temperature at midnight was 103° F. She was a 
little more quiet the next day, but refused to nurse. She did 
not vomit, however, and had two normal stools during the 
day. She was seen at 4 p.m., September 7. 

Physical Examination. She was well developed and nour- 
ished and of good color, but was very fussy and irritable. 
She kept crying out as if in pain and was constantly putting 
her hand in her mouth. The anterior fontanelle was two 
cm. in diameter and level. There was no rigidity of the neck 
or neck sign. The pupils were equal and reacted to light. 
The ear-drums were normal. There was no nasal discharge 
or obstruction. She had three teeth. The gum was much 
swollen and reddened over the left upper middle incisor, 
which was apparently on the verge of erupting. The tongue 
was clean and the throat normal. There was no rosary. 
The heart, lungs and abdomen were normal. The lower 
border of the liver was palpable two cm. below the costal 
border in the nipple line. The spleen was not palpable. 
The extremities were normal. There was no spasm or 
paralysis. The knee-jerks were equal and normal. Kernig's 
sign was absent. There was no enlargement of the periph- 
eral lymph nodes. There was no eruption. The rectal tem- 
perature was 101° F.; the pulse, 112; the respiration, 28. 

The urine was clear and contained no albumin or sugar. 

The leucocytes numbered 10,000. 

Diagnosis. Otitis media, which is strongly suggested by 
the symptoms, can be excluded on the absence of all signs 
of nasopharyngeal irritation, the normal white count and the 
normal condition of the ear-drums. Pyelitis, which often 
causes fever and symptoms of discomfort without physical 
signs at this age, is ruled out by the low white count and the 



626 CASE HISTORIES IN PEDIATRICS. 

normal condition of the urine. Tubercular meningitis, which 
must always be considered when a baby is ill and there are 
no definite symptoms except fever and irritability, seems very 
improbable in the light of the physical examination. It 
cannot be excluded, however, unless some more reasonable 
explanation of the symptoms can be found. There are no 
symptoms pointing to disease of the gastrointestinal tract. 
The low white count show^s that there is no hidden inflamma- 
tory process going on and the physical examination shows 
nothing abnormal except the swelling and redness of the gum. 
In the absence of all symptoms and physical signs of other 
conditions it seems fair to conclude, therefore, that this is 
the seat of the trouble and to make a diagnosis of Difficult 
Dentition. The fussiness and the constant putting of the 
hands to the mouth point strongly, moreover, to discomfort 
there. The fever may easily be caused by reflex irritation 
from the swollen gum. 

Prognosis. The symptoms will probably cease at once 
when the gum is lanced and the pressure relieved. 

Treatment. The gum should be lanced at once. 



UNCLASSIFIED DISEASES. 627 

CASE 199. Harold C, five years old, had always been 
well except for whooping-cough at two years, scarlet fever and 
chicken-pox at three years and measles two months before. 
He was admitted to the Children's Hospital, July 20, three 
da}^s after the onset of an infectious diarrhea. The physical 
examination and the urine were normal at that time. He 
had only a moderately severe attack of the disease, but lost 
much weight and strength. The character of the stools began 
to improve August 3, as did his general condition. The 
temperature reached normal a week later and there was no 
longer blood in the stools. Everything seemed to be going 
well, except that from time to time he had a little fever. 
The movements had diminished to two a day and he was 
beginning to sit up in bed. It had from the first been very 
difficult to keep his mouth clean, but there had been no 
ulcerations. His mouth continued to be dirty and the odor 
from it was very foul. A sloughing area, the size of a dime, 
was noticed on the inside of the left cheek about noon, 
September 2. It had not increased in size when he was seen 
the next morning, but the cheek had become much swollen 
during the night and a profuse, very foul-smelling discharge 
from the mouth had appeared. He apparently had no pain. 

Physical Examination. He was thin and pale. He was 
perfectly clear mentally, but somewhat apathetic. The left 
cheek was much swollen, but not red or hot and only slightly 
tender. There was a profuse, very foul-smelling discharge 
from the m^outh. The v/hole of the inside of the mouth was 
reddened, but there were no ulcerations, except in the left 
cheek, where there was a sloughing area, the size of a dime. 
Several of the teeth on this side were much decayed. The 
throat was normal. The heart, lungs and abdomen were 
normal. The liver and spleen were not palpable. The 
extremities were normal, as were the superficial and deep 
reflexes. The lymph nodes on both sides of the neck were 
enlarged, more so on the left. The rectal temperature was 
100° P.; the pulse, 130; the respiration, 30. 

Diagnosis. The location of the sloughing area, the marked 
swelling of the cheek without heat or redness, the foul odor 
of the discharge, the relatively low temperature and the onset 



628 CASE HISTORIES IN PEDIATRICS. 

of the trouble during the convalescence from an acute disease 
are so characteristic of Noma that it is unnecessary to con- 
sider any other condition. 

Prognosis. The prognosis is very grave. He may recover, 
but in all probability the process will extend and he will die 
of exhaustion and bronchopneumonia in the course of three 
or four days. 

Treatment. The sloughing area should be thoroughly 
burned out at once with the actual cautery. The mouth 
should be cleansed several times daily with a solution of 
peroxide of hydrogen in order to diminish the chances of the 
development of a secondary bronchopneumonia. This solu- 
tion is also especially useful because the Bacillus fusiformis, 
the probable cause of noma, is anaerobic. He should be given 
as much fresh air as possible, preferably out of doors, and fed 
freely with milk, gruel, cereal jellies, junket and milk toast. 
He must be fed with a tube, passed through the nose, if he 
will not take sufficient nourishment otherwise. Stimulation 
is not needed at present, but probably will have to be started 
by to-morrow. 



UNCLASSIFIED DISEASES. 629 

CASE 200. Joseph W. was the child of healthy parents. 
Three other children were well and one had died of diarrhea 
in infancy. There had been no miscarriages. He had had 
no known exposure to tuberculosis. He was born at full 
term, after a normal labor, and, except for whooping-cough at 
three years, had been well until he was five and one-half years 
old. He then began to complain of pain in the abdomen, and 
it was noticed soon after that his abdomen was larger than 
in the past. The abdomen had slowly increased in size since 
then and he had had pain in it from time to time. His 
appetite was not very good, but he did not vomit and his 
bowels moved regularly. He did not gain in either height or 
weight, did very poorly at school and did not care to play 
with other children. His mother thought that he was usually 
a little feverish at night. He was admitted to the Children's 
Hospital when seven years old. 

Physical Examination. He was fairly well developed and 
nourished and of good color. The heart and lungs were 
normal. The upper border of the liver flatness was at the 
upper border of the sixth rib in the nipple line; the lower 
border was not palpable. The spleen was not palpable. The 
abdomen v/as considerably enlarged and there was a rounded 
prominence in the epigastrium. Palpation revealed a mass 
about the size and shape of a large egg-plant, with the small 
end down, in the upper abdomen. It extended about three 
cm. below the navel and further to the right than to the left 
of the median line, but did not reach the costal border. Its 
anterior surface was close to the abdominal wall. It was fiat 
on percussion and not tender. It was freely moveable later- 
ally and downward but did not move with respiration. Its 
surface was smooth and it felt hard, but somewhat elastic. 
The rest of the abdomen and the flanks were tympanitic. The 
kidneys were not palpable and nothing abnormal was de- 
tected in the flanks. The genitals were normal, as were the 
extremities. A few lymph nodes, the size of beans, were 
palpable in the neck and groins. There was no evidence of 
enlargement of the bronchial lymph nodes. Rectal examina- 
tion showed nothing abnormal. The rectal temperature was 
99° F. 



630 CASE HISTORIES IN PEDIATRICS. 

The urine was clear, acid in reaction, of a specific gravity of 
1,018 and contained neither albumin nor sugar. The sediment 
showed nothing but a few small round and squamous cells. 



Blood. 




Hemoglobin, 


90% 


Red corpuscles, 


5,368,000 


White corpuscles, 


9,900 


Mononuclears, 


45% 


Polynuclear neutrophils. 


54% 


Eosinophiles, 


1% 



The red corpuscles showed nothing abnormal. 

A skin tuberculin test was very strongly positive. 

Diagnosis. The strip of tympanitic resonance between the 
tumor and the costal border and the fact that it does not 
move with respiration show that it cannot be connected with 
the liver. Tumors of the spleen are not of this shape, are 
not moveable downward and come out from under the costal 
border. Tumors of the kidney come up into the abdomen 
from the flanks, which, in this instance, are empty. It cannot, 
therefore, be a tumor of either the spleen or kidneys. These 
are, moreover, solid tumors, while this tumor has the shape 
and feel of a cyst. It cannot be a cyst of the pancreas, 
because it is superficial and freely moveable. The only other 
cysts which occur in this region are those of the mesentery. 
The mobility is consistent with this condition. The tumor 
is, therefore, almost certainly a Cyst of the Mesentery. 
These cysts are, as a rule, due to obstruction of the lymph 
vessels, but are sometimes collections of pus resulting from 
the breaking down of tubercular mesenteric lymph nodes. 
The low white count and the normal temperature are con- 
sistent with either condition. The strongly positive tuber- 
culin test, in the absence of signs of tuberculosis elsewhere, 
unless the slightly enlarged lymph nodes in the neck and 
groins are such, suggests, but does not prove, that it is the 
latter. There is no way of settling this point except by 
operation. 

Prognosis. He is in good general condition and the physi- 
cal examination shows nothing abnormal outside of the abdo- 



UNCLASSIFIED DISEASES. 63 1 

men. He should, therefore, stand an operation well. It ought 
not to be, moreover, a very difficult matter to remove the 
cyst. If it is not tubercular, its removal will cure him. If 
it is tubercular, it is very probable that there are some other 
tubercular lymph nodes elsewhere in the body which will 
not, of course, be removed. The prognosis of tubercular ade- 
nitis at this age is, however, very good with proper care and 
treatment. 
Treatment. The treatment is immediate operation. 



INDEX 



The heavy face numerals refer to the pages on which the disease named is the diagnosis of a case; the 
other figures to the pages on which the disease or condition is mentioned. 



Abdomen, examination of, 35. 

tumor of, 248, 285. 
Abscess.. 74- 

epigastric, iii. 

of brain, 562. 

of lung, 356. 

of skull, 567. 

peritonsillar, 336. 

retropharyngeal, 21, 301, 336, 575, 579. 
Acid intoxication, 191, 583, 609, 610, 

612. 
Adenitis, bronchial, 589, 

cervical, 585 

(See lymph nodes.) 
Adenoids, 18, 25, 301, 330, 331, 339, 
358, 462, 575, 579, 586. 

examination for, 22. 
Amyotonia congenita, 569. 
Anaphylaxis, 359, 361, 362. 
Anemia, 50, 435, 437, 466, 469, 472, 
477, 490, 596, 599, 602, 621. 

chlorotic type, 466. 

infantum pseudoleukemica, 473. 

pernicious, 469, 470, 478. 

secondary, 229, 234, 260, 347, 466 
470, 472, 477, 478, 483, 493- 

secondary, with spelnic tumor, 473. 

splenic, 486, 494. 
Aneurism, 119. 
Angioneurotic edema, 50, 531? 592, 593, 

602. 
Antitoxin poisoning, 606. 
Antrum, maxillary, 22. 

mastoid, 23. 
Anus, fissure of, 40, 198. 
Appendicitis, iii, 185, 186, 188, 189, 

248, 251, 285, 286, 373, 442. 
Appendix, position of, 39. 
Arthritis, acute, of infants, 624. 

infectious, 621. 

septic, 45. 
Ascites, 37, 244, 431, 437, 447. 

causes of, 244. 

characteristics of fluid in, 245. 

physical signs of, 244. 



Asthma, 358, 361. 

Atelectasis of lung, 83, 226, 227. 

Babinski's phenomenon, 46, 
Bacteriuria, 442, 453. 
Banti's disease, 494. 
Barley water, starch in, 210. 
Baths, fan, 378. 

pack, 378, 451. 

sponge, 377. 
Bednar's Aphthae, 18, 299. 
Bile ducts, congenital obliteration of, 
71, 90, 91. 

obstruction of, 437. 
Bladder, capacity of, 42. 

position of, 42. 
Blood, characteristics of, 52, 53, 54. 
Blood pressure, 29. 
Bow-legs, 43. 
Brain, abscess of, 562. 

tumor of, 563, 567, 616. 
Branchial cyst, 67. 
Breasts, engorgement of, 25, 89. 
Breck feeder, 65. 

Bronchitis, 226, 227, 256, 260, 282, 283, 
290, 326, 336, 349, 351, 353, 356, 
361, 364, 367, 460, 539. 
Bronchopneumonia, 227, 254, 260, 349, 

351, 364, 367, 589. ^ 
Bronchus, foreign body in, 356. 
Brudztnski's neck sign, 47, 

Calculi, renal, 445. 

vesical, 241. 
Calories, use in infant feeding, 152, 154, 
170, 214, 216, 218, 474, 597, 609. 
use in older children, 142, 179, 182, 

233, 280, 318, 448, 449, 613. 
method of calculation in infant feed- 
ing, 214, 216. 
need of, 450. 

table of caloric values, 449. 
Caput succedaneum, 74. 
Cephalhematoma, 74. 
Cerebellar tumor, 563. 
Cerebral hemorrhage, 106, 534, 537. 



633 



634 



INDEX 



Cerebral paralysis, 46, 77, 122, 125, 305, 

508, 519, 526, 5SS, 537, 559. 
Cerebral tumor, 563, 567. 
Cerebrospinal fluid, normal, 264, 265. 

in meningitis, 264, 265. 
Chest, anatomy of, 24. 

growth of, 14. 

position in examination of, 2S. 
Chicken breast, 26. 
Chicken-pox, 311. 
Chlorosis, 466. 
Cholecystitis, 164. ■ 
Cholera infantam, 116, 182. 
Chondrodystrophia foetalis, 618, 619. 
Chorea, 416, 423, 495, 496, 505. 
Chvostek's symptom, 48. 
Cirrhosis of liver, 431, 434, 437, 486, 

493, 494. 
Ccecum, position of, 39. 
Colic, lead, 37. 
Colitis, 37. 

Colon, position of, 39. 
Colostrum, 25. 
Congenital atelectasis of lungs, 83. 

cerebral defect, 537. 

dilatation of the colon, 128. 

dislocation of hip, 44. 

heart disease, 82. 

icterus, 90, 91. 

laryngeal stridor, 85, 339. 

malformation of bile ducts, 71, 90, 91, 
167. 

malformation of esophagus, 88. 

malformation of intestine, 69. 

muscular hypertonia, 106. 
Constipation, 127, 134, 149, 152, 168, 
194, 198, 200, 201, 216, 222, 230, 
270, 373, 374, 528, 571, 608. 
Convulsions, 339, 342, 343, 376, 377, 
501, 502, 504, 507, 508, 515, S3I, 
532, 540, 541, 581, 583. 
Craniotabes, 16. 
Cream, composition of, 208. 
Creeping, 43. ^ 

Cretmism, 17, 19, 23, 514, 519, 573, 

617, 618. 
Croup, spasmodic, S33' 
Curve of weakness, 24, 229. 
Cyanosis, enterogenous, 405. 
Cyst, branchial, 67. 

mesenteric, 630. 

ovarian, 244. 
Cystic hygroma of neck, 67. 

Dentition, 20. 
delayed, 531. 
difficult, 328, 626. 



Diabetes insipidus, 615. 
Diabetes mellitus, 609, 611. 
Diaphragm, position of, 26. 
Diarrhea, 294. 

classification of, 115, 116. 

cholera infantum, 116, 204. 

dysenteric type, 116, 202, 240. 

fermentative, 116, 172, 175. 

infectious, 145, 178, 131, 599. 

nervous, 115. 
Diastasis of recti muscles, 37. 
Diphtheria, 237, 288, 2S0, 442. 

laryngeal, 290, 3S3, 356. 

nasal, 288, 301. 

paralysis in, 557. 

intubation in, 291. 
Dropsy, idiopathic (see idiopathic 
edema). 

Ear, examination of, 22. 
Edebohls' operation, 461. 
Edema, 50, 93, 450, 602. 

angioneurotic, 50, 531, 592, 593, 602. 

idiopathic, 596, 599. 

of lungs, S3, 423, 427, 549. 
Emphysema of lungs, 358, 361, 381, 385. 
Empyema (see pleurisy, piirulent). 
Encephalitis, 342, 541, 546, 547, 562. 
Endocarditis, 324, 364. 

acute, 411, 414, 415, 416, 417, 418, 420. 

malignant, 414, 415. 
Enuresis, nocturnal, 462. 
Epilepsy, 342, 501, 502, 504, 508. 
Epiphysitis, acute, 305. 

syphilitic, 306. 
Epstein's pearls, 18. 
Erysipelas, 113. 
Erythema, 317. 
Erythema multiforme, 604. 
Erythremia, 405 

Erythrocytosis megalosplenica, 405. 
Esophagus, 21. 

congenital malformation of, 83. 

spasm of, 120. 

stricture of, 120. 
Extremities, deformities of, 43. 

examination of, 43, 44, 45. 

growth of, 13. 

position of, 45. 

size of, 45. 

spasm of, 45. 
Eyes, 23. 

reaction to accommodation, 23. 

reaction to light, 23. 

Face, growth of, 17. 
Facial phenomenon, 48. 



INDEX 



63s 



Faculties, development of, 49. 
Fat (see infant feeding). 

in skimmed milk, 210. 

in top milk, 210. 

in whole milk, 209. 
Fede's disease, 19. 
Feeding (see infant feeding). 
Fissure of anus, 40, 161. 
FontaneUes, 15. 
Fragilitas ossimn, 618. 
Friction sounds, pleural, 35. 

Gall bladder, examination of, 40. 

Gallstones, 164. 

Genitals, examination of external, 42. 

German measles, 314, 315, 316, 317. 

Glands (see lymph nodes). 

Glioma, 563. 

Glycosuria, alimentary, 609, 611. 

Grasping, 43 

Grocco's sign, 32. 

Growth, in height and weight, 11, 12. 

of chest, 14. 

of face, 17. 

of head, 14. 

relative of extremities and tnmk, 13. 

Habit spasms, 496, 
Hair, 16. 

Harrison's groove, 25. 
Head, growth of, 14. 
Head, shape of, 14. 
Hearing, 23. 
Heart, area of, 28. 

examination of, 27. 

impulse of, 27. 

sounds of, 29. 
Heart disease, 583. 

acute endocarditis, 411, 414, 415, 416, 
417, 418, 420. 

aortic insufficiency, 417. 

chronic valvular disease, 400, 403, 408, 
417, 423. 

congenital, 82, 400, 403, 406, 579. 

dilatation, 364, 409, 420, 423. 

ftmctional, 403, 408, 409, 411, 437, 447. 

malignant endocarditis, 414, 415. 

mitral insufficiency, 417, 426. 
Heart disease, mitral stenosis, 426. 

myocarditis, 411, 417, 418, 420, 427. 
Hematoma of the sternocleidomastoid 

muscle, 80. 
Hematuria, 240, 241, 445, 458. 
Hemophilia, 99, 100, 102, 103, 477. 
Hemorrhage, cerebral, 106, 534, 537. 
Hemorrhagic disease of the new-bom, 

38, 43, 99, 103. 
Hemorrhoids, 40. 



Henoch's disease, 592. 
Hernia, epigastric, 37. 

inguinal, 42, 72. 

umbilical, s^- 
Hip, congenital dislocation of, 44. 
Hirschsprung's disease, 128. 
Hodgkin's disease, 480, 486, 490, 493. 
Hydrocele, of cord, 42. 

encysted, of cord, y$. 
Hydrocephalus, 14, 15, 16, 227, 526, 529, 
534, 566, 567. 

chronic internal, 267, 522, 525, 528. 
Hydronephrosis, 458. 
Hypertonia, congeniteJ muscular, 106, 

122. 
Hypospadias, 43. 
Hysteria, $7, 565, 615. 

Icterus (see jaundice). 
congenital, 90, 91. 
neonatorum, 91. 
Idiocy, 569. 
amaurotic, 514, 516, 519. 
hydrocephalic, 514, 519. 
microcephalic, 614, 519. 
Mongolian, 17, 19, 514, 519, 520. 
Incontmence of feces, 201. 
Indigestion, 71, 116, 145, 153, 263, 278, 
3^7, 328, 331, 342, 370, 37^, 498, 
589, 593- 
acute,^ 134, 139, 172, 185. 
chronic, 122, 125, 149, 151 164, 234, 

33S, 437, 596, 602. 
from excess of carbohydrates, 115, 164. 
from excess of fat, 115, 149, 151, 154, 

164, 194. 
from excess of fat in breast-milk, 147. 
from excess of maltose, 160. 
from excess of protein, 115, 169. 
from excess of protein in breast-milk, 

167. 
from excess of salts, 115, 596. 
from excess of starch, 161, 596. 
from excess of sugar, 158, 160. 
from overfeeding, 115. 
from overfeeding with artificial food, 

145. 
from overfeeding with breast-milk, 143. 
type undetermined, 172. 
with fermentation, 116, 145, 175. 
Infant feeding, breast, 123, 152, 158, 160, 
167, 169, 176, 217, 221, 224, 227, 

340, 354, 435, 470, 529, 583, 597, 

618. 
boiling, disadvantages of, 236. 
calculation of calories, 214, 216. 
pasteurization, disadvantages of. 241. 



636 



INDEX 



Infant feeding, use of albumin water, 603. 
use of alkalies, 123, 155, 170, 224, 230, 

283, 474, 529, 597, 603. 
use of buttermilk, 154, 181. 
use of calories, 152, 154, 155, 170, 214, 

216, 218, 224, 474, 597, 609. 
use of low fat, 123, 152, 176, 217, 435, 

597. 
use of pancreatization, 170, 238. 
use of proteids, 181, 217, 221, 435, 597. 
use of salt, 597. 
use of starch, 149, 160, 170, 176, 178, 

183, 217, 238, 340, 467, 597, 603. 
use of sugar, 152, 158, 160, 169, 176, 

178, 183, 238, 340, 435, 597. 
use of whey, 123, 176, 529, 597. 
use of whey proteids, 123, 176. 
Infantile atrophy, 220. 
Influenza, 171, 257, 278, 279, 280, 282, 

292, 293, 326, 377, 430, 539. 
Intestinal obstruction, 188, 191. 
Intestinal toxemia, i82j 272, 317, 434, 

502, 534, 593, 602. 
Intestine, congenital malformation of, 

69. 
Intoxication, acid, 191, 583, 609, 610, 
612. 
intestinal, 182, 272, 317, 434, 502, 
534, 593, 602. 
Intussusception, 131, 134, 138, 177, 593. 
Irrigation of bowels, method, 178. 

Jaundice, 70, 86, 108, 397, 436, 437. 
infectious, 90, 91. 

Kernig's sign, 47. 

Kidney, amyloid disease of, 460. 

floating, 42. 

sarcoma of, 37, 240, 241, 445, 458. 

stone in, 445. 

tuberculosis of, 238, 445. 

timiors of, 42, 630. 
Kidneys, examination of, 41. 

passive congestion of, 431. 

position of, 41. 
Ejiee-jerks, examination of, 46. 
Knock-knees, 43. 
Koplik's spots, 19, 313, 314, 315, 316. 

Lachrymal glands, 23. 

Laryngismus stridulus, 85, 339, 508, 

531, 532, 579. 
Laryngitis, catarrhal, 290, 333, 339, 582. 

diphtheritic, 290, 2S3, 339- 
Laughing, 49. 
Lavage method, 172. 
Lead, colic, $y. 

poisoning, 593. 



Leucocytosis, digestive, 53. 
Leukemia, 477, 489, 586. 

acute lymphatic, 440, 470, 480, 483, 486. 
Lips, 17. 
Liver, abscess of, 437. 

amyloid, 385, 434. 

cirrhosis of, 431, 434, 437, 486, 493, 
494. 

examination of, 40. 

fatty, 385, 434, 435, 621. 

malignant disease of, 434, 437, 440. 

position of, 40. 

sarcoma of, 397, 440. 

syphilis of, 437. 
Lungs, abscess of, 356. 

edema of, 83, 423, 427, 549. 

examination of, 30. 

gangrene of, 356. 

percussion of, 30. 

position of lobes, 31. 

resonance of, 30. 

sarcoma of, 398. 

sense of resistance, 32. 
Lymph nodes, abdominal, 245, 285, 286, 
458, 630. 

axillary, 585. 

bronchial, 30, 85, 364, 589. 

cervical, 79, 323, 408, 489, 585, 586. 

epitrochlear, 48. 

general enlargement of, 48, 440, 472, 
621. 

inguinal, 72, 585. 

local enlargement of, 48. 

occipital, 48. 

tracheo-bronchial, 48, 119, 260, 326, 
356, 490, 575, 579, 585, 589. 

Macewen's s3anptom, 16. 

Malaria, 278, 282, 292, 295, 347, 414, 

452, 469, 493. 
Malformation, congenital, of intestine, 

69. 
Malformation, congenital obliteration of 
bile ducts, 71, 90, 91. 
congenital, of esophagus, 88. 
of nose, 301. 
Malnutrition, 151, 168, 216, 220, 253, 
260, 434, 472, 473, 569, 580, 621. 
from insufl&cient food, 160, 217, 223. 
from insufficient proteids, 221. 
Mastitis, 89. 
Masturbation, 511. 
Measles, 249, 282, 313, 314, 315, 316, 

364, 367, 390, 546. 
Meckel's diverticulum, 38. 

prolapse of, 94, 97. 
Mediastinitis, 430. 



INDEX 



637 



Meningitis, 37, 106, 172, 263, 267, 276, 
279, 292, 301, 342, 370, i-jT, 455, 
456, IZ^, 534, 539, 541, 546, 547, 
551, 582. 
cerebrospinal, 171, 191, 263, 264, 267, 
270, 271, 273, 276, 278, 280, 293, 
377, 455, 525' 54i, 566. 
cerebrospiaal fluid in, 264, 265. 
influenza, 539. 
pneumococcus, 541. 
serous, 534, 543. 

tubercular, 185, 191, 263, 264, 267, 
268, 270, 271, 273, 276, 278, 293, 
539, 541, 543, 546, 626. 
Meningocele, 67, 74. 

spinal, 67. 
Mesentery, cyst of, 630. 
Methemoglobinema, 405. 
Microcephalus, 514. 
Milk, composition of skimmed, 210. 
composition of whole, 209. 
home modification of, 211. 
Mouth, examination of, 17. 
Mucous polyp, 2>^. 
Mumps, 282, 323. 
Muscular dystrophy, 569 
Myelitis, transverse, 537. 
Myocarditis, 321, 364. 

Nasopharyngitis, 575, 579, 582, 625. 
Nasophar3mx, anatomy of, 22. 

examination of, 22. 
Navel, 37. 

granuloma of, 38 94, 96. 

mucous polyp of, 38. 
Neck, anatomy of, 23. 

in cretinism, 23. 

cystic hygroma of, 67. 
Neck sign, 47. 
Nekton's line, 44. 
Nephritis, acute, 321, 324, 445, 447. 

chronic, 442. 

chronic interstitial, 442, 460, 615. 

chronic parenchymatous, 442, 460. 

degenerative, 248, 583 599. 
Neuritis, multiple, 237, 305, 537, 551, 

555, 556, 557, 559. 
New-born,cerebralhemorrhagein,534,537. 

hemorrhagic disease of, 38, 43, 99, 103. 

septic infection of, 90, 91, 103, 106, 
109, 111, 167, 534. 
Noma, 628. 
Nose, 17. 
Noticing, 49. 

Obstetric paralysis, 77. 
Omphalitis, 109. 



Orchitis, 324. 

Orthostatic albuminuria, 442, 443. 

Osteogenesis imperfecta, 618. 

Osteomalacia, 618. 

Osteomyelitis, 237, 297, 299, 308, 565. 

Osteoperiosteitis, syphilitic, 308. 

Osteopsathyrosis, idiopathic, 618. 

Otitis media, 133, 267, 278, 328, 342, 

343, 345, 347, 453, 562, 582, 625. 
Ovarian cyst, 244. 

Packs, cold, 378. 

hot, 451. 
Paralysis, examination for, 46. 

cerebral, 46, 77, 122, 125, 305, 508, 
519, 526, SZS^ 537, 555, 559. 

diphtheritic, 557. 

Erb's, 560. 

facial, 77. 

hysterical, 565. 

infantile, 77, 237, 444, 537, 546, 549, 
651, 555, 556, 557, 559, 560, 565, 

569. 
obstetric, 77, 560. 

peripheral, 235, 305, 537, 551, 555, 
' 556, 557, 559. 
Parasites, intestinal, 477. 
Pasteurization (see infant feeding). 
Pavor noctumus, 498. 
Pelvis, characteristics of, 36. 

inflammation in, 248. 
Percentages in milk mixtures, 212. 
Pericarditis, 430. 

chronic adhesive, 431, 437. 
dry, 426. 

with effusion, 423, 426. 
Periosteitis, 45, 237, 297, 299, 565. 

syphilitic, 308, 565. 
Peritonitis, 69, iii, 189. 
chronic serous, 245. 
malignant, 245. 
septic general, 251, 373. 
tubercular, 37, 245, 248, 249, 251, 
285, 286. 
Perspiration, 50. 
Phimosis, 43. 
Pigeon breast, 26. 
Pleural thickening, 252, 431. 
Pleurisy, purulent, 381, 384, 385, 388, 
398, 391, 392. 
serous, 251, 356, 380, 381, 385, 394, 
397,398. : 
Pneimionia, 17, ZZ^ 82, 171, 188, 267, 
278, 279, 280, 282, 292, 293, 344, 
396, 373, 374, 377, 380, 381, 384, 
385, 390, 391, 392, 401, 419, 455, 
540, 541, 643, 562. 



638 



INDEX 



Pneumonia, acute tubercular, 384, 391. 

physical signs in, 34. 

unresolved, 388. 
Pneumothorax, 393. 
Poisoning, antitoxin, 606. 

bromide, 501. 

lead, 593. 
Poliomyelitis, 546, 549, 551, 555, 556, 

557, 559, 560, 565, 569- 
Poliomyelo-encephalitis (see poliomy- 
elitis). 
Polycythemia, 405. 
Poljoiria, 615. 
Pott's disease, 229, 237. 
Prematurity, 63, 91. 
Proteids (see infant feeding). 

need of, 450. 
Pseudoleukemia, 480, 486, 490, 493, 586. 
Pseudomasturbation 511. 
Pulse, rate of, 29. 

rhythm of, 29. 
Purpura, 435, 692. 

abdominal, 592. 

Henoch's, 592. 

rheumatica, 592. 

simplex, 592. 
Pyelitis, 267, 442, 453, 455, 456, 589, 625. 
Pylorus, position of, 38. 

spasm of, 2^, 122, 142. 

stenosis of, 38, 122, 125, 142, 528. 
Pyonephrosis, 458. 

Rales, 34. 

Rectum, anatomy of, 39. 

prolapse of, 40, 
Reflexes, abdominal, 46. 

contralateral, 47. 

cremasteric, 46. 

plantar, 46. 
Respiration, bronchial, 33. 

character of, 32. 

puerile, 32, SS- 

rate of, 32. 

ryhthm of, 32. 
Retropharyngeal abscess, 21, 301, 336, 

575, 579- 

Rhagades, 17. 

Rheumatism, 237, 297, 410, 411, 414, 
415, 416, 417, 418, 423, 425, 426, 
427, 430, 551, 505, 604, 607, 624. 

Rhinitis, diphtheritic, 17, 287, 288, 301. 
sunple, 17, 287, 301, 326, 339. 
syphilitic, 287, 301, 302, 305. 

Rickets, 15, 16, 19, 20, 25, 43, 44, 151, 
160, 198, 226, 229, 253, 256, 260, 
267, 282, 295, 30s, 331, 339, 347, 
472, 473, $22, 531, 566, 569, 573, 602. 



Rickets, fetal, 618. 

late, 234. 
Riga's disease, ig. 
Rosary, 25. 

Saliva, 18. 

Sarcoma of brain, 563, 567. 
Sarcoma, of kidney, 37, 240, 241, 445, 
458. 

of liver, 397, 440. 

of lung, 398. 

of skull, 567. 

of suprarenal capsule, 440, 567. 

of tibia, 308. 
Scalp, veins of, 16. 
Scarlet fever, 171, 278, 292, 293, 314, 

315, 317, 318, 321, 377, 442, 480. 
Sclerema, 50. 

neonatorum, S3. 
Scurvy, 45, 238, 240, 241, 296, 299, 305, 

469, 564, 624. 
Sensation, 48. 
Septic infection, 415, 583, 589. 

of new-born, 90, 91, 103, 106, 109, 

111. 534. 
Serum sickness, 606. 
Sinuses, frontal, 22. 
Skin, examination of, 60, 

color of, 50. 
Small-pox, 310. 
SmeU, 17. 
Smiling, 49. 
SpasmophiHc diathesis, 47, 339, 508, 

531, 532. 
Spina bifida, 24. 

occulta, 24. 
Spleen, chronic endothelioma of, 494. 

examination of, 41. 

position of, 41. 

tumor of, 630 
Splenomegaly, primitive, 494. 
Standing, 43. 

Starch (see infant feeding). 
Starvation, 220. 
Status lymphaticus, 576, 583. 
Stethoscope, 27. 
Still's disease, 621. 
Stomach, position of, 38. 

capacity of, 39. 
Stools, bacteriologic examination of, 61. 

blood in, 60. 

color of, 67. 

curds in, 59. 

in infancy, 54. 

membrane in, 60. 

microscopic examination of, 60. 

mucus in, 59. 



INDEX 



639 



Stools, odor of, 57. 
of breast-fed infants, 54. 
of infants fed on artificial foods, 55, 56. 
pus in, 60. 
reaction of, 56. 
starvation, 56. 
Stridor, congenital lar)Tigeal, 85, 339. 
Sucking pads, 18. 
Sugar (see infant feeding). 
Suprarenal capsule, sarcoma of, 440, 567. 
Sutures, 15. 
Sweat glands, 50. 

Syphilis, 17, 18, 20, 43, 44, 48, 63, 71, 
79, 82, go, 91, 94, 99, 103, 106, 119, 
220, 245, 287, 299, 301,^ 302, 305, 
306, 303, 437, 486, 489, 493, 522, 
529, 563, 565, 576, 615. 

T4ches c6r6brales, 48, 276. 

Tactile fremitus, 34. 

Talking, 49. 

Taste, 19. 

Tears, 23. 

Teeth, eruption of, 19. 

"Hutchinson," 20. 
Testicle, undescended, 42, 43, 72. 
Tetanus, 106, 531. 
Tetany, 45, 47, 339, 531, 532. 
Throat, digital examination of, 21. 

examination of, 20. 
Thumb-sucking, 20. 
Thymus, 27, 28, 30, 82, 579, 583. 

cyst of, 576. 

enlargement of, 85, 356, 575, 576, 580. 

examination of, 35. 
Thyroid gland, 79. 
Tongue, 19. 

Tonsihtis, 171, 278, 292, 293, 376, 586. 
Tonsils, chronic hypertrophy of, 358. 

enlarged, 331, 575, 579. 
Torticoll"s, 80, 604. 
Trousseau's s3Tnptom, 47. 
Tuberculin test, 220, 246, 254, 258, 286, 
308, 364, 368, 381, 415, 437, 486, 
489, 563, 586, 589, 630. 
Tuberculosis, 18, 48, 254, 256, 263, 285, 
286, 299, 308, 347, 408, 414, 453, 
486, 489, 546, 563, 576, 586, 587, 
589, 630. 

acute miliary, 282, 414, 



chronic diffuse, 164, 220, 261. 

family history of, 249. 

history of exposure to, 249. 

of brain, 563. 

of hip, 237. 

of kidney, 240, 445. 

of lungs, 254, 256, 257, 364, 367, 380, 

381, 384, 391. - 
of lymph nodes, 245, 256, 260, 586, 

589, 630, 631. 
of meninges, 264, 268, 271. 
of peritoneum, 37, 245, 248, 249, 261, 

285, 286, 458. 
of spine, 229, 237. 
Tumor, of abdomen, 248, 285, 630. 
of cerebellum, 563. 
of cerebrum, 563, 567. 
of kidney, 630. 
of spleen, 457, 630. 
of testicle, 397. 
of thymus, 576. 
Typhoid fever, 251, 263, 279, 280, 282, 

283, 285, 286, 414, 452. 

Ulcer of stomach, 493. 
Urachus, patency of, 38, 94, 96. 
Uremia, 270, 583. 
Ur'c acid, 240, 241, 321. 
Urine, amount of, 51. 

characteristics of, 50. 

in infancy, 51. 

in the new-born, 50. 
Urticaria, factitious, 607. 

Vagina, hemorrhage from, 43. 
Vasomotor disturbances, 48. 
Voice sounds, 34. 
Vomiting, nervous, 139, 191. 
recurrent, 139, 191. 

Walking, 43. 

Whey (see infant feeding). 

Whey, composition of, 210. 

Whey proteids (see infant feeding). 

Whooping-cough, 249, 325, 326, 364, 

3^5, 367. 
Worms, 164. 

pin- worms, 202, 462, 511. 
round worms, 204. 
tape worms, 206. 



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